PUBLICATIONS OF THE UNIVERSITY OF MANCHESTER 



Medical Series— No. XIII. 



FEEBLEMINDEDNESS IN 
CHILDREN OF SCHOOL-AGE 



Published by the University of Manchester at 

THE UNIVERSITY PRESS (H. M. McKechnie, M.A., Secretary) 

12 Lime Grove, Oxford Road, MANCHESTER 

LONGMANS, GREEN & COMPANY 

39 Paternoster Row, London, E.C. 4 

Fourth Avenue and Thirtieth Street, New York 

336 Hornby Road, Bombay 

6 Old Court House Street, Calcutta. 

167 Mount Road, Madras 




o 



FEEBLEMINDEDNESS 



IN 



CHILDREN 



OF 



SCHOOL-AGE 



BY 

C. PAGET LAPAGE, M.D., M.R.C.P. 

Lecturer in Diseases of Children to the University of Manchester; Physician 

to the Manchester Children's Hospital and to the Children's Department 

of St Mary's Hospital; Member of the Board of Governors, Sandlebridge 
Colony for the Feebleminded. 



WITH AN APPENDIX ON TREATMENT AND TRAINING 
BY 

MARY DENDY, M.A. 

Commissioner of the Board of Control; late Honorary Secretary to the 
Sandlebridge Colony for the Permanent Care of the Feebleminded. 



SECOND EDITION 



MANCHESTER : AT THE UNIVERSITY PRESS 

12 LIME GROVE, OXFORD ROAD 

LONGMANS, GREEN & CO. 

LONDON, NEW YORK, BOMBAY, ETC. 
1920 



rA t*o\ 



v .[A 



C\l* 



University of Manchester Publications 
No. XIII. 

Gift 
University 






< 

* 






TO THE MEMORY 

OF 
HENRY ASHBY 



PREFACE TO THE FIRST EDITION 

Up to the present time the immense importance to our 
national welfare of effective methods in dealing with 
the Feebleminded has not been generally realised. The 
report of the Royal Commission on the Care and Control 
of the Feebleminded, published in 1908, has, however, 
served as a stimulus, so that, latterly, there has been 
a large amount of interest taken in the subject. This 
has rendered necessary the provision of a book suitable 
for school medical officers and also for teachers or social 
workers who have to deal with feebleminded children. 
The further objects of this book are (1) To emphasise 
the importance of the subject of mental deficiency and 
of the prominent place that efficient care of feebleminded 
persons should take in the measures for the welfare of 
the community. 

(2) To point out that feeblemindedness is an inherited 
taint handed on from generation to generation, and 
that every feebleminded person, who is a free and un- 
restrained agent, may, by becoming a parent, transmit 
that taint and so affect tens or hundreds in future 
generations. 

(3) To demonstrate that the only way to deal effec- 
tively with the problem is to provide suitable super- 
vision and care, which will last during the whole lifetime 
of the feebleminded individual, and to show how such 
care may best be administered. 

I wish to express my great indebtedness to Miss Dendy 
for her help and advice, and for the material which 
she has placed at my disposal. Her appendix on the 

vii 



viii PREFACE TO THE FIRST EDITION 

Treatment and Training of Feebleminded Children adds 
immensely to the practical value of the book. 

I also wish to thank Professor Lorrain Smith for his 
help, and Dr. J. Mcllraith (Medical Officer to the 
Sandlebridge Colony), Mr. Wyatt (Director of Elemen- 
tary Education in Manchester), and Miss Dickens 
(Superintendent of the Manchester Special Schools) for 
so kindly placing material at my disposal. Most of the 
photographs were taken by Mr. Quinn. Mr. G. Lapage 
has also given me much assistance with the proofs. 

C. P. L. 

Manchester, 
November, 1910. 



PREFACE TO THE SECOND EDITION 

Very great advances have been made in the work for 
the Mentally Defective since the First Edition of this 
book was published. 

The passing of the Mental Deficiency Act and the 
progress consequent upon this have rendered necessary 
inclusion of much new material. 

The Second Edition has been long overdue, and its 
preparation was in fact begun in 1913; but war duties 
prevented its completion. 

I wish to express my thanks once more to Miss 
Dendy for her help and advice, and to the Governing 
Body of the Lancashire and Cheshire Society for the 
Permanent Care of the Feebleminded for allowing me 
access to plans and documents; and to Mr. Richards, 
Secretary to the above Society, in sending me literature 
and information when I was abroad, and for his later 
assistance with the proofs. 

C. P. L. 

Manchester, 
August, 1920. 



IX 



CONTENTS 



3HAPTER PAGE 

I. Introductory and Statistical . , 1 

II. Present Methods of Dealing with the 

Mentally Defective 23 

III. Physical Characteristics 55 

IV. Mental Characteristics .... 70 
V. Defects of Speech 89 

VI. Special Types 99 

VII. Diagnosis . 115 

VIII. Prognosis . . . . . .134 

IX. Treatment and Care 145 

X. The Cell, Reproduction, and Heredity 161 

XI. The Condition of the Brain in Feeble- 
mindedness 167 

XII. The Causation of Feeblemindedness — 

Inherited Factors .... 178 

XIII. The Causation of Feeblemindedness — 

Acquired Factors . . . .189 

XIV. Preventative Measures and General 

Considerations 197 

xi 



xii CONTENTS 

APPENDIX PAGE 

I. On the Training and Treatment of 
Feebleminded Children. Written by 
Mary Dendy, M.A 207 

II. The Detailed Examination of the Head 246 

III. The Detailed Examination of the Speech 250 

IV. The Binet-Simon Tests of Mental Intel- 

ligence 253 

V. Forms and Certificates suitable for use 
when examining a child sent up for 
admission to an institution for feeble- 
minded children 255 

VI. List of Homes, Schools and Institutions 259 

VII. Plans and Description of an Economical 
House suitable for Feebleminded 
Children 270 

Bibliography 275 

Glossary . . • . . . . 283 

Index 288 



LIST OF ILLUSTRATIONS 

PLATE 

I. GROUP OF FEEBLEMINDED BOYS WORKING AT 

sandlebridge .... Frontispiece 

TO FACE PAGE 

II. FEEBLEMINDED CHILDREN OF THE ORDINARY 

TYPE 57 

III. TRACINGS TO SHOW ABNORMALITIES IN THE 

SHAPE OF THE HEAD AS FOUND IN THE 
FEEBLEMINDED . . . .071 page 60 

IV. ABNORMALITIES OF THE EXTERNAL EAR . . 61 

V. DEFECTIVE EXPRESSIONS .... 67 

VI. DIAGRAM TO SHOW PATHS AND CENTRES THAT 
HAVE TO DO WITH SPEAKING, READING AND 

writing on page 73 

VII. CRETINISM 99 

VIII. SLIGHTER MONGOLIAN TYPES .... 103 

IX. MICROCEPHALIC, HYDROCEPHALIC AND MORALLY 

DEFECTIVE TYPES 108 

X. PARALYTIC (HEMIPLEGIC) TYPES. ATHETOID 

MOVEMENTS 110 

XI. THREE BROTHERS AND A BROTHER AND SISTER, 

ALL FEEBLEMINDED 201 

xiii 



xiv LIST OF ILLUSTRATIONS 

TO FACE PAGE 
XII. MODELS USED IN TRAINING THE SENSES OF 

SIGHT, COLOUR, FORM AND BALANCE . . 228 

XIII. PHOTOGRAPH OF WYATT HOUSE . . . 245 

XIV. PLANS OF BUILDING SUITABLE FOR A RESIDEN- 

TIAL SCHOOL 270 



LIST OF TABLES 



TABLE PAGE 

I. THE COMPARATIVE FREQUENCY OF THE TYPES 

OF FEEBLEMINDEDNESS 57 

II. COMPARISON OF THE HEIGHTS, WEIGHTS AND 
HEAD MEASUREMENTS OF FEEBLEMINDED AND 
ORDINARY SCHOOL CHILDREN 66 

III. COMPARISON OF THE AGE OF LEARNING TO WALK 

AND TALK AND THE DEGREE OF MENTAL DEFECT 83 

IV. THE PHYSIOLOGICAL ALPHABET (WYLLIE) . . 94 

V. RESULTS OF THE DETAILED EXAMINATION OF THE 
HEADS OF ORDINARY CHILDREN AND FEEBLE- 
MINDED CHILDREN OF SCHOOL-AGE COMPARED 249 

VI. TABLE OF WORDS SUITABLE FOR MAKING THE 

CHILD PRONOUNCE THE VARIOUS CONSONANTS 251 

VH. TABLE ILLUSTRATING FREQUENCY OF SUBSTITU- 
TION 252 



DIAGRAMS 

DIAGRAM I. SHOWING THE PERIODS OF LIFE AFTER 

CONCEPTION 168 

DIAGRAM II. SHOWING DJHERITANCE OF FEEBLE- 
MINDEDNESS . . facing page 186 
xv 



CHAPTER I 

INTRODUCTORY AND STATISTICAL 

History. — In 1904 it was thought necessary to appoint 
a Royal Commission on the Care and Control of the 
Feebleminded, and as a result of their report, the 
Mental Deficiency Act was passed on August 15, 1913. 
Thus was reached the culmination of the efforts which 
had been going on in various quarters to promote the 
welfare of the mentally deficient. The pioneer work 
of Seguin, Itard, Howe, Wilbur and others in distin- 
guishing the treatment and care of "idiots " from that 
of " lunatics " has been described in other text-books ; 
here we shall deal chiefly with the history of the 
movement in England. 

In the past the words " lunatic " and " idiot " have 
stood for two divisions of mentally deficient persons, 
the one implying " disorder of the mind in a person 
who has been in possession of his faculties," and the 
other " a state of mental incapacity, which has been 
present from birth or from an early age." The Lunacy 
Acts included under their jurisdiction both lunatics and 
idiots, but the Idiots Act of 1886 (since repealed, 1913), 
dealt with idiots apart from lunatics, and by the use 
of the word imbecile, as referring to mental defect of 
a lesser degree than idiocy, recognised a sub-class of 
the mentally defective. Later a further sub-class of still 
higher mental power, the feebleminded, was recognised. 

Most people are familiar with the type known as the 
" village idiot," and anyone who has to deal with such 

A 1 



2 INTRODUCTORY AND STATISTICAL 

persons will know how helpless they are, how often 
they form the butt of gibes and jests, how they can be 
goaded to fits of passionate and uncontrollable rage 
during which they may commit acts of violence, and 
finally how subservient they are to the will and sugges- 
tion of others. Such persons were obviously in need of 
care and help ; but in spite of the fact that much atten- 
tion had been devoted to lunatics, it is only compara- 
tively recently that any other than the idiots with 
the lowest grade of intellect have been generally 
recognised as being in want of care. The existence 
of a very large number of persons who, though cer- 
tainly of too low a mental level to look after them- 
selves without assistance, are still of a higher level 
than idiots, had in the past only been partially recog- 
nised, and though various more or less isolated attempts 
had been made to care for special classes of the weak- 
minded no comprehensive scheme had been adopted. 
The great majority of such persons had been dealt with 
by various authorities such as the poor-law, the prisons, 
the inebriate homes, and the education authorities, 
according to whether they were destitute, habitual 
criminals, drunkards or too deficient to benefit from 
instruction in the ordinary schools, as the case may have 
been. Obviously it was wrong to make it impossible 
for them to come under care until they had committed 
an offence of some sort, and it is better to take them 
under care and prevent such offences. 

Past efforts at care. — In the attempts that have been 
made to deal with this class of mental deficiency we 
can trace several distinct movements. First, there was 
the establishment of the institutions known as the idiot 
asylums, which were founded at a time when idiocy was 
thought to be more or less curable, and the importance 
of lifelong care had not been realised. 

To quote the Commissioners : — 

In general we may say that the object of the asylums is 



PAST EFFORTS AT CARE 3 

primarily educational, and that, originally at least, they were 
the outcome of a belief that in many cases special education 
would prepare " for the duties and enjoyments of life " the 
children or young persons, who gained admission to them. 

Since the regulations of the asylums included the 
discharge of pupils after a period varying from four to 
seven years, it is evident that lifelong care formed no 
part of the original idea of their founders. 

The first idiot asylum, Earlswood, was founded in 
1847, but a small school had been established at Bath 
in 1846, and this became the Magdalen Hospital School. 
Other idiot asylums were established later, the Eastern 
Counties at Colchester in 1859, the Western Counties 
at Starcross in 1864, the Royal Albert at Lancaster in 
1864, and the Midland Counties at Knowle in 1868. 
In all, these institutions provided accommodation for 
about 1,900 cases. To these must be added the im- 
portant colony at Darenth, under the Metropolitan 
Asylums Board. But it should be pointed out that 
until a few years ago when they changed their names 
to " Training Schools for the Feebleminded," these 
asylums, except Starcross, were largely devoted to the 
care of the lower grade cases. 

Secondly, taking the Poor Law Authorities, the 
Commissioners showed that, though the Guardians had 
had permissive powers of making provision for the ment- 
ally defective class, they had not evolved any suitable 
scheme of dealing with such persons on the ground of 
their mental condition, but, had treated them rather on 
the ground of their pauperism and need of relief, the 
mentally defective being then kindly looked after but 
maintained rather than treated, and no attempt being 
made to separate the Various grades. The evidence on 
this point is, as the Commissioners say, " quite con- 
clusive " : — 

It comes almost entirely from persons who as Inspectors .••.". 
or as Guardians are thoroughly familiar with the facts, and it 
relates practically to the whole country. There are special 



4 INTRODUCTORY AND STATISTICAL 

arrangements here and there . . . but it is admitted that, as 
a whole, the accommodation now provided for these persons is 
insufficient, unsuitable and unsatisfactory. It is not asserted 
that they are treated with unkindness . . . nor are the Poor 
Law Guardians throughout the country to blame. The system 
of indoor relief is merely a housing system and . . . there has 
sprung up a demand for a more discriminating and individual 
treatment of mentally defective persons. . . . 

The practice of giving outdoor relief or of boarding- 
out such cases has also had very bad results in England 
and is undesirable for many reasons. Its limitations will 
be discussed later. 

The Guardians have had power to make use of other 
institutions, and to pay for the maintenance of the 
mentally defective there ; in some instances, especially 
after the report of the Commission, they did avail them- 
selves of this power, but not nearly to a sufficient extent. 

Thirdly, taking the Education Authorities, the Educa- 
tion Act of 1870 gave the school boards the duty of 
dealing with all educable children, and the establish- 
ment of schools for the physically defective soon followed 
(1872). The Royal Commission on the Blind, Deaf and 
Dumb (1889) recommended that every parent should 
cause his or her child " to receive instruction suitable to 
it," and that " with regard to feebleminded children, 
they should be separated from ordinary public scholars 
in public elementary schools in order that they may 
receive special instruction and that the attention of 
school authorities be particularly directed towards that 
object." The later recommendation arose from the 
evidence of several witnesses, especially Drs. Shuttle- 
worth and Warner, with regard to those children 
defective in sight, hearing, and speech because they were 
mentally deficient. London and seven provincial towns* 
established such schools, but the cost was a very heavy 
charge on local expenditure, when unsupported by a 

* Towns that first established special schools for feebleminded 
children are Birmingham, Bradford, Bristol, Leicester, Liver- 
pool, London, Manchester, Oldham and Salford, Leicester being 
the first of all. 



PAST EFFORTS AT CARE 5 

Government grant, and representations were made for 
special legislation in favour of feebleminded children. 
General F. J. Moberly, who was then Chairman of the 
Sub-Committee of the London County Council Schools 
for the physically defective, gave evidence before this 
Commission and later became the Chairman of the Sub- 
Committee in charge of the Special Schools for the 
Mentally Defective. 

In 1876-77 a Special Committee of the Charity 
Organisation Society of London reported on the educa- 
tion and care of idiots, imbeciles, and harmless lunatics, 
estimating their number at 49,041, and recommending 
the establishment of schools and asylums in every large 
centre or group of counties. 

Again in 1890 the same Society appointed a special 
committee to consider and report on " the public and 
charitable provision made for the care and training of 
the feebleminded, epileptic, deformed, and crippled." 
This Committee issued in 1891 an interim, and in 1892 
a final report, which embodied the results of an examina- 
tion of a very large number of school children by Dr. 
Francis Warner and others, who found that approxi- 
mately 1 per cent, of the children examined required 
special care and training. 

In 1893 the Elementary Education (Blind and Deaf 
Children) Act was passed, and by it the teaching of blind 
and deaf children became compulsory. In 1895 a Com- 
mittee under the auspices of the British Medical 
Association, the Charity Organisation Society of London, 
the British Association for the Advancement of Science, 
the International Congress of Hygiene and Demography, 
and other public bodies issued " A Report on the 
Scientific Study of the Mental and Physical Conditions 
of Childhood with particular reference to Defective 
Children " from the Parke's Museum, Margaret 
Street, W.* 

* See Shuttleworth and Potts, Mentally Deficient Children. 



6 INTRODUCTORY AND STATISTICAL 

The interest in defective children created by these 
various reports was great, and led up to the appoint- 
ment of a Departmental Committee on Defective and 
Epileptic Children in 1896. The Committee consisted 
of the Rev. F. W. Sharpe, C.B., then Her Majesty's 
Chief Inspector of Schools ; Messrs. Pooley and Newton 
of the Education Department; Mrs. Burgwin and Miss 
Douglas Townsend; and of Professor Wm. Smith and 
Dr. Shuttle worth ; Mr. H. W. Orange acting as Secre- 
tary. Their report was issued in 1898, and one of the 
main conclusions they formed was " that children exist 
who, on the one hand, are too feebleminded to be pro- 
perly taught in ordinary elementary schools by ordinary 
methods, and, on the other hand, are not so feeble- 
minded as to be imbecile or idiotic. These feebleminded 
children exist as a distinct class from imbeciles, they are 
not certified as imbeciles, not provided for as imbeciles, 
they differ both from ordinary children and from 
imbeciles in the treatment they require during their 
school-life." The Committee also found that approxi- 
mately one per cent, of the children in the public 
elementary school classes appeared to be feebleminded, 
and they recommended that such children should attend 
school when possible rather than remain idle at 
home. 

These suggestions were embodied in the Elementary 
Education (Defective and Epileptic Children) Act of 
1899, defective children being there defined as " children 
who, not being imbecile and not merely dull and back- 
ward, are by reason of mental and physical defect 
incapable of receiving proper benefit from the instruction 
in the ordinary public elementary schools, but are not 
incapable, by reason of such defect, of receiving benefit 
from instruction in such special classes or schools as are 
in this Act mentioned," and the period of compulsory 
education for these children was extended to 16 years 
instead of 14, as for ordinary children. 



INCREASING EFFORTS FOR CARE 7 

By this Act the authorities were empowered but not 
compelled (1) to establish special classes for defective 
children in some of their schools ; (2) to board them out 
in houses near to special classes or schools; (3) to 
establish either special day or boarding schools for them. 
This Act was really a very moderate measure, and only 
touched the fringe of the subject since its powers were 
permissive only, and also since it made no provision for 
the bad cases of mental defect. For epileptic children 
boarding schools only were allowed. 

Fourthly, taking Voluntary Agencies, for some 30 
years much attention has been paid to means for help- 
ing feebleminded women, especially those who had been 
led into disgrace by reason of their mental defect, and 
Lady Frederick Cavendish established the first home for 
this purpose. Her efforts were followed by Miss Stacey 
in Birmingham, Miss Grayson in Liverpool, and Miss 
Scott at Hitchen. 

Increasing Efforts for Care. — Largely owing to the 
establishment of Special Day Schools, which revealed the 
very large numbers of the weakminded children for 
whom no special provision was made, the subject of 
feeblemindedness assumed increasingly more importance, 
and in 1896 was founded the National Association for 
Promoting the Welfare of the Feebleminded. 

At this time a new development in the care of the 
feebleminded began with the foundation in 1898 of the 
Lancashire and Cheshire Society for the Permanent Care 
of the Feebleminded, since hitherto no large society or 
institution had grasped and emphasised the essential 
point in dealing with the problem, that of lifelong 
care. 

The foundation of this last society followed directly 
as a result of the efforts of Miss Mary Dendy and the 
late Dr. Henry Ashby. Miss Dendy's attention had 
been attracted to the large numbers of obviously weak- 
minded children in the elementary schools under the 



8 INTRODUCTORY AND STATISTICAL 

Manchester School Board, and Dr. Ashby examined and 
reported on 500 mentally defective children selected by 
her from 39,600 scholars. 

This examination, entailing as it did a questioning of 
the parents, only served to emphasise the point that, 
valuable as special day schools may be, the work done 
in them must be largely wasted and nullified if the 
children are discharged at the age of sixteen, the most 
critical period of their lives, to become in many instances 
the parents of children similar to themselves. Miss 
Dendy's efforts led to the foundation of the above 
society, to which she was for fifteen years Honorary 
Secretary, and which has now attained important dimen- 
sions. The late Mr. C. H. Wyatt, when Director of 
Elementary Education in Manchester, did a great deal 
to aid the work of the Society. The whole policy of this 
Society is based on the fact that only lifelong care of 
the feebleminded is satisfactory, and the success of its 
colony at Sandlebridge demonstrates the feasibility and 
value of this method of caring for the persons of weak 
mind. There is no doubt that the colony school system 
with lifelong care is by far the most satisfactory, and 
wherever possible it should be adopted for all grades of 
cases. Nobody who is familiar with the problem, and 
also with the results of a colony such as that at Sandle- 
bridge, can have the least doubt on this point. 

Royal Commission. — In April, 1903, a petition 
signed by some 140 influential persons especially inter- 
ested in the subject, was sent to the Home Secretary 
pleading for the appointment of a Royal Commission 
" to consider and report upon the existing provision for 
Idiots, Imbeciles, and the Defective or Feebleminded, 
and to make recommendations." This led up to the 
appointment in 1904 of the Royal Commission on the 
Care and Control of the Feebleminded. 

The Marquis of Bath was first appointed Chairman of 
the Commission, but he resigned and the Earl of Radnor 



ROYAL COMMISSION 9 

was appointed in his place. The other members were (2) 
W. P. Byrne, Esq., Principal Clerk to the Home Office; 
(3) C. E. H. Chadwick-Healey, Esq., K.C. ; (4) 
C. E. H. Hobhouse, Esq., M.P. ; (5) F. Needham, Esq., 
M.D., Commissioner in Lunacy; (6) H. B. Donkin, 
Esq., M.D. ; (7) J. C. Dunlop, Esq., M.D. ; (8) H. D. 
Greene, Esq., M.D. ; (9) The Rev. H. N. Burden, 
Manager of Brentry and other Inebriate Reformatories ; 
(10) W. H. Dickenson, Esq., M.P., Chairman of the 
National Association for promoting the welfare of the 
Feebleminded; (11) C. S. Loch, Esq., Secretary to the 
Charity Organisation Society; (12) Mrs Hume Pinsent, 
Chairman of the Special Schools Sub-Committee of the 
Birmingham Education Committee. 

Their report consisted of eight volumes ; volumes one 
to four being minutes of evidence, volume five appendix 
papers, volume six the reports of the medical investiga- 
tors, volume seven the report on the visit of certain of 
the Commissioners to America, and volume eight the 
Report Volume. The report was issued in August, 1908, 
and served to correlate and focus the knowledge on the 
subject, to bring forward much fresh evidence, and to 
bring out prominently the urgent need of a comprehen- 
sive scheme for dealing with the feebleminded. 

The Commissioners were at first directed to consider 
the methods of dealing with idiots, epileptics, imbecile, 
feebleminded, or defective persons not certified under 
the Lunacy Laws, but later the scope of the enquiry 
widened, and they were also directed to enquire into 
the Lunacy Laws with a view to the suggestion of some 
scheme that would provide care for all persons of 
deficient intellect whether they were lunatics, dements, 
idiots, imbeciles, epileptics, or feebleminded. The Com- 
missioners examined 248 witnesses, obtained informa- 
tion from foreign countries, and visited American 
institutions. At the outset it was found that there were 
no available statistics; medical investigators were, 



10 INTRODUCTORY AND STATISTICAL 

therefore, appointed in various districts, their duties 
being to examine the following groups of persons : — 

(1) Children in Public Elementary Schools. 

(2) Children and Adults in Poor Law Institutions. 

(3) Children and Adults in receipt of Outdoor Relief. 

(4) Persons known to Sanitary Authorities. 

(5) Persons relieved by Medical Charities. 
{6) Persons known to General Practitioners. 

(7) Children and Adults in various Charitable Institutions 

and Common Lodging Houses, Training Homes, and 
Reformatories and Industrial Schools. 

(8) Persons to be heard of from other sources. 

(9) Known to the Police. 

(10) Idiots of the District in Idiot Asylums. 

(11) Inmates of Prisons. 

(12) Inmates of Inebriate Homes. 

As a result of this report, the Mental Deficiency Act 
of 1913 was passed. But before discussing its provisions 
and effects, it is advisable to examine some further facts 
and figures brought out by the evidence given before the 
Royal Commission. 

Classification and Definitions. — Strictly speaking the 
term Mental Deficiency includes all persons of unsound 
mind, and such persons can be divided into two 
classes : — 

(1) Lunatics,* dements, or insane persons who from 
disorder of the mind or from a decay of their mental 
faculties have lost the power of managing themselves 
or their affairs. 

(2) Aments, or persons who, because their brain is in- 
capable of normal development, have never had and 
never will have the power of managing themselves or 
their affairs. 

There has been and still is a tendency to limit the 
term Mental Defect to Aments as distinguished from 
Dements. In this book we shall use the term mentally 

* There is in many quarters to-day a strong demand that the 
word lunatic shall be abolished. It is not agreed as to what term 
shall be substituted for it. As a matter of fact, it is little used 
by the Authorities, excepting in legal documents. 



CLASSIFICATION AND DEFINITIONS 11 

defective in reference to class (2), the aments, the terms 
idiot, imbecile, and feebleminded and moral imbecile 
being used to designate various grades. We shall dis- 
miss class (1), or lunatics, with the two remarks that 
the Commissioners recommend that the words "lunatic" 
and " asylums " should be superseded and those of 
" persons of unsound mind " and " hospital " substi- 
tuted, and that it is entirely undesirable that lunatics 
should be treated in the same institutions as the mentally 
defective. 

Of the three grades of aments or mentally defective 
persons the feebleminded are intellectually the highest, 
the idiots the lowest, and the imbeciles intermediate. 

Definitions. — The definitions of the three grades 
adopted by the Act are : — 

(a) Idiots — that is to say, persons so deeply defective in mind 
from birth or from an early age as to be unable to guard them- 
selves against common physical dangers. 

(b) Imbeciles — that is to say, persons in whose case there 
exists from birth or from an early age mental defectiveness not 
amounting to idiocy, yet so pronounced that they are incapable 
of managing themselves or their affairs, or, in the case of children, 
of being taught to do so. 

(c) Feebleminded persons — that is to say, persons in whose case 
there exists from birth or from an early age mental defectiveness 
not amounting to imbecility, yet so pronounced that they require 
care, supervision, and control for their own protection or for, the 
protection of others, or, in the case of children, that they by 
reason of such defectiveness appear to be permanently incapable 
of receiving proper benefit from the instruction in ordinary 
schools. Dr Goddard has suggested the name " Moron " for this 
type of mentally defective person. 

(d) Moral Imbeciles* — that is to say, persons who from an early 
age display some permanent f mental defect coupled with strong 
vicious or criminal propensities on which punishment has had 
little or no deterrent effect. 

These definitions emphasise the lifelong and incurable 
character of the mental affliction, and distinguish it from 
(1) temporary mental affections, and (2) from backward- 
ness or retarded mental development, which is due to 

* Imbecile is not a good word. f Lifelong is a better word. 



12 INTRODUCTORY AND STATISTICAL 

adverse factors in infancy and childhood. Temporary 
insanity may be cured and a backward child may be 
brought up to the normal level by suitable treatment, 
but a mentally deficient child, though amenable to treat- 
ment and training to some extent, can never be rendered 
normal. 

Causation. — When dealing with the causation of 
mental defect, the Commissioners found that twenty- 
five out of thirty-five witnesses attached supreme im- 
portance to the fact that, in a very large proportion of 
the cases of mental defect, there is a history of mental 
defect in the parents or near ancestors. The twenty- 
five witnesses, who held this opinion, had all had a very 
large experience, and had devoted special attention to 
the subject. Sir Clifford Allbutt said : — 

I regard feeblemindedness (if not accidental) as always heredi- 
tary, or in other words it is a ratio of variation. I have never 
met with a case of manufactured feeblemindedness apart from 
some accident at birth or afterwards. ... I attach great weight 
to inheritance. . . . Feebleminded persons are prolific; the thing 
can only be bred out. 

The late Dr. Ashby, Medical Officer to the Special 

Schools at Manchester, said : — 

In at least 75 per cent, of the children with amentia that I have 
examined there was a strong probability that the amentia was 
hereditary and primary (i.e., spontaneous, not due to external 
influences). He further says that he has observed no special 
tendency in the children of alcoholics or of women who suffer 
privation during pregnancy or in those children who live in 
unfavourable conditions subsequent to birth, to develop amentia. 
The term "Amentia" is here used to cover all grades of mental 
defect in early life. 

Dr. Bevan Lewis said : — 

There is not the least doubt of it' in my mind. I look upon 
feeblemindedness as a germinal variation just as all " variations " 
are. 

Dr. Tredgold found evidence of a neuropathic inheri- 
tance in 80 per cent, of his cases. 

Mr. Frederic Wilkinson, Director of Education, Bolton 



CAUSATION 13 

Education Committee, gave evidence to the effect that 
in almost every case where parents of mentally defective 
children appeared before the Committee or before magis- 
trates, it was found that the parents themselves were 
similarly affected. 

In support of the importance of heredity in the causa- 
tion of feeblemindedness were the facts that a large 
majority of " experienced witnesses " held this view as 
did "numerous observant individuals other than medical 
who visit the homes of the feebleminded," and " the 
almost overwhelming probability from the biological 
standpoint of this view being true." Professor Sir E. 
Ray Lankester held : — 

that congenital feeblemindedness is spontaneous originally and 
truly hereditary subsequently and is not brought about by starva- 
tion and other such conditions : it is more probably due to easy 
conditions of life and the absence of the selection that obtains 
amongst more primitive men. 

Dr. Archdall Reid expresses the opinion that the great 
majority of the cases of feeblemindedness are innate and 
tend to be inherited. 

With regard to the fertility of mentally deficient 
persons, the Commissioners quote the evidence of " their 
medical investigators and of Miss Dendy, a very experi- 
enced witness," to show that in spite of the fact that 
there is a large mortality in the children bom to mentally 
deficient persons, they tend to have large families. 

On the other hand it is only fair to quote Dr. Mercier's 
evidence, which was : — 

clear and consecutive and amounts to the conclusion that, not 
only is the frequent transmission of feeblemindedness by inherit- 
ance not proved, but, also, that the organic defect of brain 
which underlies feeblemindedness may be often the result of 
external influences which during childhood affect the growth of 
the brain injuriously. 

In conclusion, the Commissioners summed up : — 

1. That both on the grounds of fact and of theory there is the 
highest degree of probability that " feeblemindedness " is usu- 



14 INTRODUCTORY AND STATISTICAL 

ally spontaneous in origin — that is, not due to influences acting 
on the parent — and tends strongly to be inherited. 

2. That, especially in view of the evidence concerning fertility, 
the prevention of mentally defective persons from becoming 
parents would tend largely to diminish the number of such 
persons in the population. 

3. That the evidence for the conclusion strongly supports 
measures, which on other grounds are of pressing importance, 
for placing mentally defective persons, men and women, who 
are living at large and uncontrolled, in institutions where they 
will be employed and detained; and in this, and in other ways, 
kept under effectual supervision so long as may be necessary. 

They added that, in their opinion : — 

the general feeling of the people would at present rightly con- 
demn any legislation directed chiefly or exclusively to the pre- 
vention of hereditary transmission of mental defects by surgical 
or other artificial measures. The possibility of adopting such 
measures having been referred to by twenty-one of the witnesses 
but only recommended by three. 

Proportion of the Feebleminded to the General 
Population. — The statistics given on pages 192 and 193 
of the Commissioners' report are very striking. Apart 
from lunatics (or, as the Commissioners recommend 
they should be called, " persons of unsound mind ") at 
least one in 217 or 0.46 per cent, of the population is 
mentally defective, i.e., is either idiot, imbecile, feeble- 
minded, or a moral imbecile. When children on the 
school registers are considered, the proportion is still 
higher, partly because mentally deficient persons tend 
to die earlier in life and partly because proportionately 
more children than adults come under supervision and 
observation on the ground of mental defect. Taking the 
average of the results obtained from the figures collected 
by the medical investigators the proportion was 1 to 127 
or 0.79 per cent., being approximately 1.0 per cent, in 
urban districts and 0.5 in rural. This difference may be 
due to the greater facilities for medical inspection apper- 
taining in the towns at the time the estimate was made. 
In some towns the proportion was higher than 1 per 
cent., being in Birmingham 1.12 per cent., in Manchester 



PROPORTION TO GENERAL POPULATION 15 

1.24 per cent., and in Lincoln 1.10 per cent. Thus in 
these districts there is at least one mentally deficient to 
about eighty-five ordinary school children. There is a 
preponderance of males in the proportion of 3 — 2. Out 
of 436,833 children on the school registers in the areas 
investigated 3,437 were mentally defective, and of these 
2,590 or 75 per cent, were in need of provision. In 
England and Wales there are probably at present well 
over 50,000 mentally deficient scholars on the registers, 
and that 35,804 of these are in actual need of provision 
and care (the total number of children on the school 
registers being given as 6,044,394). It must be noted 
that these figures refer only to school registers, and do 
not necessarily include all mentally deficient children. 
These figures are confirmed by later reports, and the 
estimate is more likely to be too low than too high. 

Natality and Mortality. — With regard to the natality 
and mortality of mentally defective persons, the Com- 
missioners deplore the lack of sifted and precise evidence, 
but quote some valuable statistics of Dr. Tredgold's, 
which show that the average number to each family is 
very large, being about seven or eight, and that, though 
there is a large mortality, there is a considerable sur- 
vival. The Commissioners state that the evidence 
before them cannot be taken as a sufficient basis for 
generalisation, but, so far as they go, the figures and 
statements support the opinion that, during the years 
of procreation and child-bearing, there should be control 
and supervision in the case of mentally defective men 
and women. 

From the evidence of the medical investigators it 
seems that a large number of feebleminded men and 
women drift into the workhouse before they are thirty 
years of age, and, with regard to the maternity cases 
amongst feebleminded women, Dr. Melland of Man- 
chester found that of nineteen feebleminded women in 
the lying-in wards of the workhouse infirmaries, in all 



16 INTRODUCTORY AND STATISTICAL 

but two cases the children were illegitimate, and one 
of these two women had had an illegitimate child before 
she was married; all of the women were young. Dr. 
Tredgold found that of 61 feebleminded mothers, 19 
were legally married and 42 had had illegitimate 
children. 

The general conclusions and recommendations on page 
201 include the following paragraphs : — 

In dealing with the classes idiot, imbecile, feebleminded and 
moral imbecile, we are dealing with conditions chiefly inherited 
and subject therefore, to amelioration only to the extent to which 
the mental and physical force available in the individual ap- 
proaches to the normal. But this conclusion does not preclude 
a considerable advance in knowledge and self-command among 
the higher grades of the defective — so far at least that they may 
be trained so as to contribute materially to their self-support. 

The problem . . . affects very largely education, Poor Law and 
prison administration, and the treatment of it by one authority 
would greatly reduce the charges and simplify the obligations 
of other authorities dealing with these branches of public work. 

Mental Defect and Crime. — After examining a large 
number of expert witnesses, including Dr. Scott, London 
House of Detention for Males, Miss Dendy, Mr. A. A. 
Allen, Chairman of the London Special Schools Com- 
mittee, the late Dr. Ashby, Dr. Savage, Dr. Mott, the 
late Sir T. Clouston, Mr Legge, then Inspector of Refor- 
matory and Industrial Schools, and Sir Edward Fry, 
the Commissioners summed up that, on general grounds, 
many competent observers were of the opinion that : — 

if the constantly recurring fatuous and irresponsible crimes and 
offences of mentally defective persons are to be prevented, long 
and continuous detention is necessary. From the earliest age, 
when they appear before the magistrates as children on remand 
or as juvenile offenders until and throughout the adult period of 
their lives, the mentally defective, at first reprimanded and re- 
turned to their parents, then convicted and subjected to a short 
sentence and returned to their parents, and then later continu- 
ally sentenced and re-sen benced and returned to their parents 
and friends till for crimes of greater gravity they pass to the 
convict prisons, are treated, as this reiterated evidence shows, 
without hope and without purpose, and in such a way as to allow 
them to become habitual delinquents of the worst type and to 



MENTAL DEFECT AND RESPONSIBILITY 17 

propagate a progeny which may become criminal like themselves. 
This, as has been said, is an evil of the very greatest magnitude. 
The absolute and urgent necessity of coping with it is undeniable. 

242 of 2,353 prisoners, or 10.28 per cent., were 
mentally defective, and this is probably an underesti- 
mate, because other observers place the percentage as 
high as 20 per cent. 

Mental Defect and Criminal Responsibility. — 
After listening to the evidence of experts and quoting 
that of Mr. Troup, Permanent Under-Secretary to the 
Home Department, and of Mr. Shadwell, one of the 
Commissioners in Lunacy, the Commissioners con- 
cluded : — 

We find therefore — and there is evidence with regard to it 
from all quarters — that there is also another larger* class of 
persons who can often be hardly distinguished from the 
" certifiably insane," who are " morally incapable," " socially 
dangerous," and " obviously weakminded," who are " not thought 
to be certifiable " and who " from weakness of mind are really 
not wholly responsible." 

One scheme submitted to the Commissioners was the 
expansion of the industrial school system so as to meet 
the needs of the mentally defective, but that they are 
not in favour of such a scheme is shown by the follow- 
ing quotation : — 

In the case, however, of children or young persons, who are 
mentally defective, reform, in the sense of influencing and 
educating them in such a way that they become normal members 
of society, is in most instances impossible. They can only 
develop within the limits of their defective or retarded brain 
power. Hence for them not a definite time-limited sentence, 
but a supervision that may be extended for a long time, some- 
times for life, may in many instances be required. . . . Yet as 
a precedent the Reformatory and Industrial Schools are valuable. 
They recognise the right of the non-responsible offender to 
to special disciplinary and educational treatment. 

It is evident, therefore, that mentally defective per- 
sons should be treated on the ground of their mental 

* Larger than the lunatic class 



18 INTRODUCTORY AND STATISTICAL 

condition, and not on the ground of their criminal 
offences. 

Mental Defect and Drink. — 62.7 per cent, of habitual 
inebriates were found to be mentally defective, and the 
conclusions reached are, that there should be an exten- 
sion of the legal powers of detention and control of such 
cases, not as criminals and drunkards, but as persons 
of feeble mind. Dr. Branthwaite, Inspector under the 
Inebriates Act, stated that many chronic inebriates are 
none other than feebleminded persons, drunkards simply 
because they are feebleminded. Dr. Mott pointed out 
that the weakminded react more readily to alcohol than 
do normal persons. The superintendent of the Brentry 
Certified Reformatory (Dr. Fleck) stated that he could 
not conceive the possibility of 70 per cent, of inebriates 
ever acquiring sufficient self-control to be able to keep 
themselves from drunkenness and support themselves. 
Many other expert witnesses gave similar evidence, and 
it is plain that a very large proportion of the present- 
day chronic inebriates should be treated on the ground 
of their mental weakness and not as criminals. Regard- 
ing the more far-reaching effects of alcohol, the report 
ran as follows : — 

We are not called on to decide between the various well-known 
opinions which are held regarding the causal relationship of 
alcohol and alcoholism and mental defect, still less between the 
conflicting views concerning the possibility of alcoholism in the 
parents having any direct action on the germ or organism of the 
offspring, and thus affecting the well-being of the race. ... It 
is sufficient to insist upon the salient and incontrovertible facts 
that many chronic inebriates are mentally defective; that many 
mentally defective persons are liable to suffer speedily, seriously 
and permanently from the effects of alcohol; that in any case 
alcohol in the parent leads practically to many evils in the family 
by destroying the organisation of the home and by bringing 
about neglect, ill-treatment, starvation and disease among the 
children. 

Mental Defect and Illegitimacy. — Witness after 
witness examined before the Royal Commission spoke of 
the urgent need of detention for feebleminded girls. 



MENTAL DEFECT AND ILLEGITIMACY 19 

The late Sir Thomas Clous ton, Physician Superinten- 
dent of the Royal Edinburgh Asylum, said : — 

feebleminded young women are subject to overwhelming tempta- 
tions and pressure towards sexual immorality. Many of them 
have had illegitimate children and this often at very early ages. 
One had seven such children. I look on this source of immorality 
as an extremely grave one in our social life. When illegitimate 
children are borne by such young women the chances are enor- 
mously in favour of their turning out to be either imbeciles, or 
degenerates, or criminals. 

Other witnesses,* who held responsible positions, gave 
similar evidence, showing how feebleminded women give 
birth to child after child, all of them illegitimate, and at 
the same time pointed out that there was considerable 
doubt whether any machinery existed to provide control 
for these women. The girl could be kept in the work- 
house until she was sixteen, or if the guardians adopted 
her, until she was eighteen, but after that time she is 
free to take her discharge. The consequences of her 
doing so are that she will probably return to give birth 
to a child and then again take her discharge. Cases 
where feebleminded women took their discharge and 
returned again and again to give birth to illegitimate 
children are well-known to most boards of guardians, 
who were, nevertheless, up to the passing of the Act, 
powerless to prevent it. 

Mental Defect and Institutional Care. — Even when 
institutional care was available it was not of the right 
kind, i.e., lifelong, as is shown by the following : — 

Speaking before the Royal Commission of the results 
of Training, Dr. Caldecott, Medical Superintendent of 
Earlswood, says : — 

Roughly speaking two-fifths of our patients are idiots, two- 
fifths low-grade imbeciles and one-fifth high-grade and trainable 

* Mr Baldwin Fleming, one of the General Inspectors to the 
Local Government Board; Miss Skinner, Superintendent Nurse 
of the York Union Infirmary; Mrs Ruspini, representing the 
Church Penitentiary Association; Miss Helen Benington, Lady 
Superintendent of the York Rescue Homes. 



20 INTRODUCTORY AND STATISTICAL 

imbeciles. Of 341 cases discharged during the last fifteen years 
3.25 per cent were earning wages, 3.81 were at home and very 
useful, 7.5 per cent, at home and useful, and the rest, 85.5 per 
cent, were no good, and should have been taken care of for life. 

At Lancaster 37 per cent, were high grade, and 9 per 
cent, of those discharged were earning wages, 33.5 per 
cent, at home and 40.3 per cent, in workhouses or 
asylums : the conclusion reached being that none of the 
cases, be they competent workers or not, ought to go out 
into the world. As Dr Douglas, the then Medical Super- 
intendent said : — " If they have learnt a trade, they still 
turn to common forms of labour, and, if their friends let 
them idly loaf about, no wonder they get into mischief." 

These figures and facts all serve to show that the 
efficient care of our feebleminded is one of national im- 
portance, and yet, even after recent events, compara- 
tively few people have much connected knowledge of the 
subject. This ignorance has led to gross errors in the 
past. Ireland quotes a case, related by Howe, in which 
for economical reasons an idiot male pauper from one 
town was allowed to marry an idiot female pauper from 
another, and in consequence the authorities had ulti- 
mately to support the pair and the three idiot children 
born to them. Mistakes of this kind are not likely to 
occur now that legislation for control and education of 
all persons of feeble mind has spread, but they serve to 
emphasise the need for suitable control. 

As a result of the report of the Commission several 
attempts were made to promote legislation which would 
give suitable powers to deal with the urgent need of 
better care for the mentally defective. In 1912 two 
Bills were introduced in the House of Commons, one by 
Mr. G. Stewart, M.P., and one by the Home Secretary, 
the Right Hon. R. M'Kenna. Roth these Bills passed 
the second reading, and were referred to Standing Com- 
mittees. After several postponements the latter Bill was 
re-introduced in March, 1913, and was finally passed on 
August 15th, 1913, its provisions coming into force on 



MENTAL DEFECT AND INSTITUTIONAL CARE 21 

April 1st, 1914. Section 67 of the new Act repealed the 
Idiots Act of 1886. 

The following documents were issued by the various 
directing bodies to those who would actually be con- 
cerned in administering the details of the Act. They 
are important, and can be seen in " The Law relating 
to the Mentally Defective," H. Davey, Stevens & Sons, 
Ltd., London, or can be purchased from Government 
publishers : — 

(1) Provisional regulations made by the Secretary of 
State and issued on April 2nd, 1914. These are exten- 
sive, and cover not only the duties of the various bodies 
who have to administer the Act, but also set forth rules 
for the governance of certified institutions and homes. 
Supplementary regulations were issued on April 30th, 
1914. 

In addition regulations were issued with the concur- 
rence of the Local Government Board to deal with the 
Section relating to Poor Law Administration for Mental 
Defectives, and others with the concurrence of the Lord 
Chancellor to deal with the Sections relating to Lunacy 
Act Administration. 

(2) Rules under Section 44 (5), determination of place 
of residence. 

(3) Provisional regulations made by the Board of 
Education under Section 2 (2) of the Mental Defi- 
ciency Act, 1913, accompanied by model arrange- 
ments as set forth in a documentary form; also by a 
circular letter, which explained the views of the Board 
in the administration of the Act by Local Education 
Authorities, both issued in March, 1914. 

(4) A circular letter sent out by the Local Government 
Board to Boards of Guardians and Joint Committees, 
and one sent out by the Home Office to Clerks and 
Justices. 

(5) A " circular to County and County Borough 
Councils," i.e., the Local Authorities under the Act, sent 



22 INTRODUCTORY AND STATISTICAL 

out by the Board of Control on April 2nd, 1914, giving 
them instructions, a " Memorandum as to Grants to 
Voluntary Societies,' 5 and " Suggestions lor Institutional 
Rules." 

More recent documents throw some light on the pro- 
gress of the work. In November, 1916, the Board of 
Control issued a circular letter to Local Authorities press- 
ing for economy in administration because of the excep- 
tional circumstances arising out of the war. This 
circular has limited the activities of authorities, and 
caused much of their constructive work to be postponed .- 

The circular letter pointed out that there was a 
66 prevailing dearth of institutional accommodation," 
and thus makes it clear how great is the need of con- 
structive work. 

They give the cases which are most urgently in need 
of institutional treatment, as (1) women under poor-law 
care who are likely to have illegitimate children on dis- 
charge, more especially if they have venereal disease ; (2) 
young women now at large or about to leave institutions 
who are in danger of corruption; (3) children about to 
leave special schools with no decent homes to go to and 
unable to protect themselves; (4) youths who are a 
source of local corruption, and industrial and reforma- 
tory school children who are found to be defective and 
need control. 

The duties of proceeding with the task of ascertain- 
ment and the provision of supervision for these defec- 
tives in the area are emphasised, and notes re finance 
and reception contracts (which should be five yearly) 
are given. 



CHAPTER II 

PRESENT METHODS OF DEALING WITH MENTAL DEFECTIVES 

There were up to the passing of the Mental Deficiency 
Act in 1913 and the formation of the Board of Control 
comparatively few organisations devoted to the primary 
purpose of caring for the feebleminded. 

There are now various agencies providing for the 
care of mentally defective persons, all working either 
under the direction of the Central Authority, i.e., the 
Board of Control administering the Act, or in co- 
operation with it. These agencies are : — 

(a) Board of Control. 

(b) Local Authorities established under the Act. 

(c) Poor Law Authorities under the Ministry of 
Health. 

(d) Education Authorities administering the Elemen- 
tary Education (Defective and Epileptic Children) Acts, 
1899-1914. 

(e) Voluntary Associations. 

(/) Guardianship by approved individuals. 

Taking these in order : — 

(a) The Board of Control. — The formation of the 
Board of Control has led to an advantageous simplifi- 
cation of the methods of dealing with the feebleminded. 
This Board is charged with the general superintendence 
of matters relating to the supervision, protection and 
control of defectives. It consists of not more than six- 
teen Commissioners, of whom four are legal and four 
medical and, at least two, women. In addition to exer- 

23 



24 METHODS OF DEALING WITH DEFECTIVES 

cising general control the Board certifies, approves, 
supervises and inspects institutions and homes, visits 
defectives, provides and maintains institutions for 
defectives of dangerous and violent propensities and 
takes such steps as may be necessary for ensuring suit- 
able treatment of cases of mental deficiency. 

The Board of Control has charge of the administra- 
tion of the Lunacy Acts of 1890 to 1911, as well as the 
Mental Deficiency Act, and the Commissioners in 
Lunacy holding office at the time of the passing of the 
latter Act became members of the Board. 

(b) Local Authorities established under the Act. — 
These are the Councils of Counties or County Boroughs 
and the London County Council, except in the case of 
Lancashire where the Lancashire Asylums Board is the 
Local Authority. These councils are charged with 
the duty of forming a Committee for the purpose of 
administering the powers given to them under the 
Act. To these Committees, in addition to members 
of the Council, can be co-opted Poor Law Guardians 
and other persons who have special knowledge of the 
subject, and a proviso is made that some of the members 
must be women. These local authorities have com- 
pulsory, obligatory and permissive powers. They must 
care for and protect all defectives not of school age, 
i.e., under 7 and over 16 years of age, who are found 
to be in need of care. (Sec. 2. (1) (b)). Their obliga- 
tory duties are set forth in clause 30 (a-h) of the 
Act. They have no compulsory duty for children be- 
tween the age of 7 and 16 unless they are notified by 
the Education Authorities that these defectives need 
care. Their obligatory and compulsory powers are sub- 
ject to financial arrangements as set out in the circular 
letter of the Board of Control to the Local Authorities, 
dated April 2nd, 1914, which represents the payment of 
one-half the cost of performing such duties. 

Their permissive powers are much wider in scope, but 



LOCAL AUTHORITIES, MINISTRY OF HEALTH 25 

Local Authorities are not allowed to spend more than 
|d. in the pound from the rates in any one year. They 
should take steps to assist all defectives in their area 
and they are urged to co-operate with other authori- 
ties or voluntary agencies in every possible way. They 
are instructed to note that different institutions are 
needed for different classes of defectives and that much 
economy can be effected in providing suitable institu- 
tions if co-operation with other authorities is complete. 
They may build institutions alone or in combination 
with other authorities or they may arrange a contract 
with already existing institutions (including those of 
Poor Law Guardians with the concurrence of the 
Ministry of Health), if approval is given by the Board 
of Control. 

They are also instructed wherever possible to assist 
by kindly supervision those defectives who are not 
properly cared for in their own homes, it being pointed 
out that maintenance at home or under guardianship, 
if rendered efficient, is much more economical than 
institutional care. 

It is also their duty under the Act, as detailed in the 
provisional regulations, to compile a register of all defec- 
tives " subject to be dealt with " in their area, ascer- 
taining at the same time through a Medical Officer the 
degree of mental defect : and to find and supervise 
suitable individuals who are willing to undertake 
guardianship. 

(c) The Poor Law Authorities and the Ministry 
of Health (late Local Government Board). — It is still 
the duty of Poor Law Authorities to provide for defec- 
tives whose maintenance is chargeable to them or who 
are in receipt of relief, but it is probable that a gradual 
reduction in the number of defectives so dealt with will 
take place because many will be intercepted by the 
action of the new authorities under the Act and placed 
under care. It is not considered desirable that defectives 



26 METHODS OF DEALING WITH DEFECTIVES 

should be cared for in workhouses,* therefore Poor Law 
Authorities are directed to make arrangements for in- 
stitutional or other care. Several Poor Law Authorities 
can combine and form joint committees and make suit- 
able arrangements, but if there are not a sufficient 
number of defectives to render such an arrangement an 
economical one they should make an arrangement with 
the Local Authorities or in the case of educable children 
with the Local Education Authorities. Arrangements 
may also be made direct with residential schools, volun- 
tarily managed, which are conducted under the certi- 
ficate of the Board of Education. The Poor Law Autho- 
rities are also directed to help in compiling the register 
of defectives in their area. 

The circular letter of the Local Government Board 
to Boards of Guardians and Joint Committees issued 
on March 31st, 1914, emphasises most of these points 
and in addition points out that Poor Law Guardians 
are mentioned as suitable to be made members of the 
Committees formed by the Local Authorities. This 
letter urges Poor Law Authorities to co-operate in a 
friendly spirit with the Local Authorities and, should 
they wish to combine with any other Poor Law Autho- 
rities in order to form joint institutions, to communi- 
cate first with the Local Authorities and confer with 
them about the arrangements for such extra provision 
of care. 

The Poor Law Authorities are also directed not to 
hesitate in notifying to the Local Authority through the 
Ministry of Health and the Board of Control those 
of their cases which are better under the care of the 
Local Authorities, i.e., (1) Defectives under the age 
of 21 who cannot receive proper care by the Poor Law 
Authorities. (2) Women who have illegitimate children 

* A later circular letter from the Board of Control gave per- 
mission for this as a temporary war economy measure if such 
premises were made separate. 



EDUCATION AUTHORITIES 27 

or are prostitutes. (3) Those who need care and are 
likely to take their discharge. (4) Moral imbeciles. 

(d) Education Authorities. — The Elementary Educa- 
tion (Defective and Epileptic Children) Act, 1914, 
amended the permissive powers of the Act of 1899 by 
making it the duty of the Local Education Authority 
to provide for the education of mentally defective 
children. The same Act conditionally provided for the 
enforcement of attendance of such children at day or 
residential schools. Finally, the Education Act, 1918, 
extended the provision of the 1914 Act so as to apply 
to physically defective and epileptic children. The 
Education Authorities deal with all educable defectives 
between 7 and 16 years of age.* 

The Mental Deficiency Act requires that children so 
dealt with shall on or before reaching 16 years of age 
be notified by the Education Authority to the Mental 
Deficiency Authority if there is reason for believing that 
continued care is necessary. It is satisfactory here to 
quote the experience of the Incorporated Lancashire 
and Cheshire Society for the Permanent Care of the 
Feebleminded, conducting the Sandlebridge Residential 
Schools in Cheshire, to the effect that such cases are 
almost invariably so reported, and subsequently adop- 
ted, with full responsibility for maintenance. 

The Mental Deficiency Act made it compulsory 

for the Local Education Authorities to ascertain what 

children within their areas are defective and to find 

out which of these are non-educable and to notify to 

the Local Authorities the names and addresses of all. It 

was, however, still optional whether they dealt with 

the educable mentally defective children in their area 

who did not come under Section *2 of the Act until 

1914, when it was made compulsory. 

* It is permissive for the Education Authorities to deal with 
children under the age of seven years. The Regulations for 
Special Schools, 1920, state on page 8 that no child may be 
admitted to a Special School under the age of two years. 



28 METHODS OF DEALING WITH DEFECTIVES 

However, the Board of Education issued Regulations 
on March 24th, 1914, to come into force on April 1st, 
1914, which made amongst others the following pro- 
visions. 

Dealing with children between the ages of 7 and 16, 
the School Medical Officers are the Medical Officers for 
the purposes of the Act. 

If the certifying Medical Officer states that defective 
children are uneducable or unsuitable for special schools 
then the Local Education Authority must notify the 
case to the Local Authority under the Mental Deficiency 
Act. The Local Education Authority must, as shown 
above, if they think that further care is desirable, also 
notify the Local Authority when any defective child in 
a special school, or school, or institution is nearing the 
age of sixteen and is likely to be withdrawn. If they 
think that the case need not be notified then they must 
refer it to the Board of Education for decision. It must 
be pointed out that backward children are in quite a 
different position as regards educability to defective 
children. These two classes of children should on no 
account be taught in the same school or the same 
classes.* Sir George Newman in his report for 1917, 
dealing with the mentally subnormal child, states that 
the number of mentally defective children is 30,000 and 
that there are 10 — 20 per cent, of dull and backward 
children in addition. The Board of Education also 
issued a list of : — 

Model arrangements for Education Authorities. — 

These include the following points. The head teacher 

of any school shall bring to the notice of the Local 

Education Authority and the School Medical Officer 

any child who appears to be defective. The last named 

* Education Authorities should provide classes for backward 
children as was done in 1914 by the Manchester Education Com- 
mittee. (See Annual Report of Chief Medical Officer of the Board 
of Education for 1917, p. 104.) 



EDUCATION AUTHORITIES 29 

reports the result of his inspection on the form provided. 
The periodical school medical inspection will also help to 
find defective children. 

In the special schools all cases must be examined by 
the School Medical Officer at least once a year to ascer- 
tain (1) whether the child is fit to go to the ordinary 
schools; (2) whether the child is unfit for the special 
school ; and (3) whether though fit for the special school 
on the ground of educability, the child is unsuitable 
because his or her presence at the special school is 
detrimental to the interests, discipline and progress of 
the other children in the school (i.e., through being a 
moral imbecile). It is also the right of any parent or 
guardian to claim a re-examination any time after a 
period of six months has elapsed from the last examina- 
tion. 

The Local Education Authority must arrange for 
similar inspections of children in their area who are 
attending schools other than their own. If defective 
children are educable in special schools but are better 
under other supervision or guardianship then they must 
take steps to notify the Local Authorities. 

In regard to Blind and Deaf children who in addition 
may or may not be defective, the Local Education 
Authorities are instructed to obtain particulars about 
such cases and about their progress at school if they 
are at school and then to consider whether they should 
be notified as defectives or not. The Elementary 
Education Act (Blind and Deaf Children), 1893. 

The Board of Education issued a circular on March 
30th, 1914, stating amongst other things that the 
Regulations refer to notification only and the Model 
arrangements to ascertainment of numbers and degree 
as well as notification. It is compulsory for the Local 
Education Authorities to take steps to ascertain the 
numbers and degree of defect of those defective children 
in their area, and the Chief Medical Officer to the Board 



30 METHODS OF DEALING WITH DEFECTIVES 

of Education lays especial stress on the need for such 
ascertainment in his Report for 1917, page 110. 

The circular points out that idiots and imbeciles are 
ineducable and that some low-grade feebleminded 
children are also ineducable, but urges a fair trial of all 
such low-grade feebleminded first before notifying them 
to the Local Authorities. 

It also urges that defective children who are educable 
but whose presence in the special school is considered 
to be detrimental should be given a fair trial also, be- 
cause many of them improve very much with proper 
teaching and can often be taught to overcome the habits 
which make their presence detrimental to other children. 
If possible such children should, if the training of the 
special school does not suffice, be given a trial in a 
residential school because of the greater effect of con- 
tinuous supervision in eradicating habits of such nature. 

Children who have minor obnoxious habits or are 
given to a petty pilfering are often curable by such 
means, but true moral imbeciles (see p. 80) are not, 
and are found to be detrimental to the interests of 
other children. 

Defective children of school age who are notified to 
the Local Authorities as in need of better care and 
guardianship should continue to attend the special 
schools if possible under the new arrangements for their 
care. 

It is also pointed out that Local Education Authori- 
ties have considerable power in that parents are under 
an obligation to see that their children attend school. 

The Local Education Authorities are also urged to 
help in ascertaining the number and whereabouts of any 
other defectives in their area either over or under the 
age of seven. 

It is explained that Schedule F (see Appendix V., 
p. 258) is a long form, but that it has been carefully 
compiled and is in its present form for good reason. 



SPECIAL SCHOOLS 31 

The certifying Medical Officer is instructed to use 
the evidence which can be supplied by the teacher as 
to the mental state of the defective. 

Finally, the need of kindly co-operation with the 
parents or guardians is emphasised. 

Special Schools. — In 1917, 56 Local Education Autho- 
rities had established 177 special schools (two of them 
residential). Voluntary bodies had established 16 
schools. The accommodation so provided was for 
15,249 children. The estimated number of mentally 
deficient children was upwards of 30,000. 

Therefore it is evident that in spite of the efforts 
made in some large towns, the provision of facilities for 
the suitable education of feebleminded children may be 
very small. This means either that the child drags 
along hopelessly in one of the ordinary schools, wasting 
the time and energy of the teacher and the rest of the 
class, or that he is given up as imbecile and stays 
at home, sinking deeper and deeper into mental stag- 
nation and needing continual watching and care by his 
mother. 

On the other hand, special schools are to some extent 
harmful, without organised lifelong control after the 
child has left school. It was certainly foolish to train 
and give a simple education to a large number of 
children yearly, and then to let them loose on society ; 
because in spite of the work done by the after-care 
associations, many of them sink to low levels and swell 
the ranks of those needing relief. As Dr Kerr, Medical 
Officer to the London School Board, says : — 

A considerable proportion show little moral restraint, some are 
almost without speech, some seem incapable of work, others work 
without progress or intelligence; very frequently, too, they are 
addicted to staying out or even wandering at night, and many 
of this last class come into the hands of the police. Some have 
bad habits and immoral tendencies are common. Many are capable 
of control when in the Special School, but speedily become irregu- 
lar and uncontrollable on leaving it. . . . About one-third will 
be capable of materially contributing to their own livelihood after 



32 METHODS OF DEALING WITH DEFECTIVES 

leaving, one-third will partially contribute but require an After- 
Care Association of some kind to look after them, whilst the 
remainder should not be allowed to mix with the rest of the 
community, but should receive some kind of custodial treatment. 

After quoting various sets of figures concerning the 
children who have left the special schools the Com- 
missioners summed up : — 

No figures could better show the necessity of supplementing the 
special classes by other means, only 17 per cent, of one set of 
children getting good work and the larger number of children 
returned as " lost " or "at home " (not doing work) show the 
need of some after-care and supervision. It appears that even 
allowing for the exclusion of cases at the outset as unsuitable (of 
too low a grade) for the special classes, 47 per cent, will never 
earn their own living, 28 per cent, would probably earn under 
control, and 22 per cent, would be possible wage earners. 

and concluded :— 

We may conclude then that the results of this survey confirm 
the general opinion that the special school system is rather an 
incident in the general scheme than of main importance in itself 
and is . . . not the central point of any such scheme. 

Provision is made by a minute of the Board of 
Education, dated 3rd February 1915, for a repayment 
to the Local Education Authority of one-half the expen- 
diture incurred in maintaining mentally deficient children 
in residential schools and for incidental expenditure 
thereon. Also for a similar repayment in respect of 
charges incurred by the Authority in respect of the 
establishment, enlargement or alteration of residential 
schools, and in respect of the interest on or repayment 
of capital raised for the purpose of contribution to such 
schools. 

Thus it will be seen that any Local Education 
Authority who takes up the question of dealing with 
the defective children in its area can be of the greatest 
assistance to the general scheme. 

But better provision is needed for care or supervision 
on leaving school, and this absence of organisation for 
lifelong care has in the past taken away nine-tenths of 



VOLUNTARY ASSOCIATIONS 33 

the value of special schools; but they have served 
a useful purpose in that they have kept registers and 
records of the feebleminded children in their district, 
and in that they have brought out and emphasised the 
need of lifelong care. 

(e) Voluntary Associations. — These take several 
forms : — 

(1) The Central Association for the Care of the 
Mentally Defective, — This in an incorporated body, 
formed largely on the suggestion of Sir William Byrne, 
Chairman of the Board of Control, to assist in the ad- 
ministration of the Mental Deficiency Act. Its Executive 
Council is composed of members representing the 
County Councils Association, the Association of Educa- 
tion Committees, the Association of Poor Law Unions, 
Medico-Psychological Association, Asylums Boards 
Metropolitan and Lancashire, Charity Organisation 
Society, Church Army, Salvation Army, and a large 
number of other representative bodies. The objects of 
the Central Association are set forth as follows : — 

1. To do all such things as may, in the opinion of 
the Council of the Association, conduce to the efficiency 
of voluntary work, whether paid or unpaid, in connec- 
tion with the Mentally Defective, or with any persons 
coming under the supervision of the Board of Control, 
or which may tend to promote or ensure the suitable 
treatment of defectives in England and Wales. 

2. To render assistance, either directly or indirectly, 
through other bodies, societies, or persons, to Public 
Authorities in the administration of Acts relating to 
the care, control, treatment or education of defectives, 
when such assistance may be requested by such 
authorities. 

3. To form, or assist in the formation of, Local 
Voluntary Associations in the different statutory areas in 
England and Wales, such associations to have as their 
main object the co-ordination of work for defectives in 

c 



34 METHODS OF DEALING WITH DEFECTIVES 

the area, and particularly the friendly visiting in their 
own homes of defectives not in Institutions. 

4. To promote co-operation between Voluntary 
Societies dealing with defectives and between Public 
Authorities and Voluntary Societies, and to act as a 
means of communication between Local Voluntary 
Associations and Voluntary Bodies and Government 
Departments or Public Authorities. 

5. To organise the training of teachers, visitors, 
guardians, attendants and others concerned in the care, 
treatment and supervision of defectives, and to assist 
in providing such persons for Public Authorities, 
Voluntary Associations or Institutions. 

6. To keep records of (a) Defectives moving from 
one area to another; and (b) Societies, Institutions, 
etc., dealing with defectives. 

7. To provide, or assist in providing, places of safety, 
observation homes, occupations or occupation centres 
for defectives, and to make special provision for 
" double " * defectives. 

8. To issue literary publications, leaflets and pam- 
phlets. 

9. To promote, watch, support or oppose any legisla- 
tion or amendment of existing legislation, relating to 
defectives. 

10. To assist in the care of individual defectives who 
are not already under the Statutory Authorities in all 
areas where no Local Voluntary Associations are 
formed. 

(2) The National Association for Promoting the 
Welfare of the Feebleminded, — The work of this body 
has already been referred to on page 7. It has been 

* A " double " defective is a child who is defective in two 
respects, for instance a child epileptic and feebleminded or blind 
and feebleminded. It is obvious that these children may be 
difficult to place in an institution because these usually make pro- 
vision for one type of defect only, and cannot take cases needing 
exceptional care. 



INSTITUTIONS 35 

in existence since 1895, and has done a very important 
work in developing and co-ordinating the work for the 
Feebleminded through all the times when the different 
movements have been in progress. 

(3) Institutions, Residential. — The privately-managed 
residential Institutions have dealt for the most part 
with the higher grade and more improvable cases, and 
it is found that when dealing only with such cases the 
cost is much reduced. Even when dealing with the 
highest grade cases it must not be thought that they 
can be fitted to look after themselves, and lifelong care 
should be the primary object of all institutions. The 
evidence given shows the advantages to mental 
defectives of a well-ordered, disciplined life. 

The Lancashire and Cheshire Society for the Per- 
manent Care of the Feebleminded with its institution 
at Sandlebridge has provided the best illustration of 
this class of home and the results with the children are 
excellent. Only high-grade cases have been ac- 
cepted from the first. The want of legal powers of 
detention formerly gave great difficulties with the 
parents, who were either actuated by selfish motives or 
could not be made to see the need of lifelong care. 
As Miss Dendy said in her evidence before the Royal 
Commission, " the results of putting these children into 
boarding schools are simply wonderful. Neither boys 
nor girls show the least restlessness. They (the big 
ones) are as easily guided as little children." 

Institutions supported by Voluntary Agencies and 
certified by the Board of Control can, under agreement 
with their managers, be utilised by the Local Autho- 
rities, but such Institutions cannot otherwise be used 
for cases sent for care by an order from a judicial 
authority. 

All such institutions must be approved by the Board 
of Control and be subject to visiting and supervision 
and be carried on under the Board's regulations. 



36 METHODS OF DEALING WITH DEFECTIVES 

(4) Voluntary Associations have been formed in some 
of the Council and Borough Areas, and these work in 
close relationship with the local authorities and are 
affiliated with the Central Association for the Care of 
the Mentally Defective. The Central Association has in 
fact done very much to promote their formation. The 
objects and methods of such Associations are summed 
up as follows : — 

To visit and befriend defectives living at home and 
to endeavour to secure through various organisations 
and societies regular visitors for such defectives. 

To visit and supervise at the request of the Local 
Authority under the Mental Deficiency Act defectives 
who are under 6i supervision " under Section 30 (b) of 
the Act. 

To secure for defectives through the Local Authority 
under the Mental Deficiency Act, 1913, or other autho- 
rities or charitable agencies, admission to homes and 
institutions, medical treatment and advice, occupations, 
etc., or such other assistance as they may require. 

To co-ordinate the work of the various societies 
dealing with defectives in their area. 

To make special provision and to secure medical 
advice and treatment for doubtful cases; also to assist 
in providing observation Homes and to provide, or assist 
in providing, occupation centres, etc., for defectives. 

After-care Committees do work of great value, be- 
cause, under the Act, there is no compulsory after-care, 
except in those cases which are judged to be bad enough 
to be notified by the Local Education Authorities. 

Committees for the care of defectives in any area 
can work best by : — (1) undertaking supervision of those 
leaving special schools or institutions and going to their 
homes ; 

(2) finding out suitable persons for guardianship and 
visiting and supervising the work of such persons; 

(3) helping in the supervision and care of any 



AFTER-CARE COMMITTEES 37 

defectives in their area who are not helped under the 
Act. (MacMurchy.) 

The following points show how great is the need for 
after-care : — 

Sir George Newman, using the evidence from 
London, Liverpool, Frankfurt and other large towns, 
concluded that 40 to 45 per cent, were unemployable. 
But it is significant that the After-care Committee 
of Birmingham, established in 1901, through the agency 
of Mrs Hume Pinsent, who has done so much for the 
furtherance of methods of dealing with the feeble- 
minded, reported in 1910, after nine years' investigation, 
that of 650 cases, only 18 per cent, were doing remunera- 
tive work, and at least 65 per cent, were not. After four 
years of trial, the Employment Bureau was given up 
because of 6( the impossibility of obtaining and retain- 
ing ordinary situations for any but an extremely limited 
number of our high-grade cases." Situations may be 
found, but the feebleminded do not retain them, 
especially when " they get older and the difference 
between them and their fellows is accentuated." The 
1915 Report states the aptitude for work soon fails 
after leaving school and especially after the age of 21. 

In practice, defectives are fit for few posts, except 
those in which a kindly employer makes special allow- 
ances for failings. 

But apart from employment under competitive 
conditions, supervision is of great value, and even the 
highest grade of feebleminded is in great need of such 
supervision and guidance. 

For instance, a Midland County Voluntary Associa- 
tion reports that their visitors generally undertake a 
district in which they are well known; therefore 
friendly relations are readily established. Where the 
home surrounding have been unsatisfactory, it has been 
possible in most instances to remove the defective to 
better surroundings, and the visitors have been, in 



38 METHODS OF DEALING WITH DEFECTIVES 

many cases, instrumental in obtaining improvements 
in the conditions under which a particular defective was 
working, or in obtaining more suitable employment, 
etc. 

The Board of Control recognises the great value of 
the work of such voluntary agencies and is empowered 
to make to them grants in aid of their expenses. 
(M. D. Act, Section 46 (2).) 

(/) Guardianship by Private Individuals. — The 
powers and duties of such guardians are denned in 
General Home Office Regulations, Sections 201-217. They 
include the following : — No corporal punishment can be 
inflicted, full provision for education, recreation and 
occupation of the patient has to be made, notice has 
to be given within a period of seven days of the patient's 
reaching the age of 21 years and suitable arrangements 
must be made for medical attendance. 

Guardians are subject to inspection and have to keep 
books and comply with the regulations laid down. 

Any patient becoming unsuitable for guardianship 
must be notified to the Board of Control and to the 
authority paying for maintenance and will be removed 
to an institution, if advisable. 

It can be seen therefore that guardianship is recog- 
nised by the Board of Control as a valuable and 
economical way of providing care for defectives of 
certain classes. 

Certain chosen children thus placed under kindly and 
efficient guardianship will probably be as well or even 
better cared for than by other means, provided (1) 
that the need for lifelong care is fully realised and 
provision made to prevent any break in the continuity 
of such care; and (2) that if the child becomes unsuit- 
able for guardianship because of age and sexual 
development or for any other reason, he or she is 
promptly removed to an institution. But it must always 
be remembered that guardianship to be efficient has to 



GUARDIANSHIP 39 

be of a high level and that only a small proportion of 
defectives are really better under guardianship . 

In addition, experience in the care of defective 
children teaches us that those coming from their homes 
to institutions are much more difficult to manage and 
train if they come later in their life. 

It is not easy to keep a defective who is under 
guardianship from undesirable influences from outsiders 
or chance happenings, and such influences may lead 
to bad effects which are difficult to overcome and which 
would never have been started if the child had been 
under institutional care. 

It is probable then that both on account of the 
difficulty of finding efficient guardians and on account 
of the difficulties just mentioned, only a small propor- 
tion of defectives will be suitable for such care. Those 
suitable will be defectives for whom sufficient money is 
available to secure continuity of guardianship for life 
and whose nature and disposition is such that (1) 
outside influences have little detrimental effect; and 
(2) there is no danger of the defective becoming a 
danger to society by any sexual development. 

Placing under Control. — Defectives can be placed 
under the Control of Institutions or Guardians, volun- 
tarily or compulsorily. Only certain defectives can be 
dealt with compulsorily, i.e., those subject to be dealt 
with under the Act; but a defective placed voluntarily 
under control can be placed under compulsory control 
if the Board of Control decide that he cannot be satis- 
factorily dealt with elsewhere. 

Placing under control voluntarily takes place at the 
instance of the parent or guardian in the case of idiots 
or imbeciles, or of the parent only in the case of feeble- 
minded under the age of 21. Thus feebleminded 
children can be placed under control by the parent, 
but when under control in this manner and not under 
an order, he or she may be withdrawn after due notice 



40 METHODS OF DEALING WITH DEFECTIVES 

at the instance of the parent, unless, on appeal to the 
Board of Control, that body decide within 14 days that 
further detention is desirable in the interests of the 
defective. 

Placing under control compulsorily takes place if 
defectives are subject to be dealt with under the Act; 
i.e. — 

(1) Defective children notified by the Education 
Authorities as needing such care, either because they 
are not educable at special schools, or are, as moral 
defectives, detrimental to the interests of other children 
at these schools. 

(2) Defective children coming before courts and 
becoming liable to be sent to or being in Industrial 
or Reformatory Schools. 

(3) Defective children found to be neglected or 
abandoned or cruelly treated, or without visible means 
of support; and, 

(4) Defective children who are in Lunatic Asylums. 
Defective adults " subject to be dealt with, 55 include 

those who are criminals, or in need of care for neglect 
or cruelty, or habitual drunkards, or women who are 
in receipt of Poor Law relief at the time of giving birth 
to or being pregnant with an illegitimate child. 

Petitions. — In all such cases, whether voluntary or 
compulsory, unless a Judicial authority has already 
dealt with the case and made an order, a petition is 
presented. A petitioner must state that the person to 
whom it relates is a defective and subject to be dealt 
with, and whether a previous petition has been pre- 
sented. The petition must be signed by the petitioner and 
one other person (who may be one of the persons giving 
a medical certificate). It is accompanied by two medical 
certificates, and is presented to a Judicial Authority, 
who, after considering the case, decides whether to make 
an order or not. 

No one can present a petition or sign a medical 



PETITIONS 41 

certificate who is financially interested in the effects of 
the defective, or in the institution to which he is to go. 
Nor can any relative of a defective sign his medical 
certificate. 

Two medical certificates are needed, one that of an 
authority approved by the Board of Control, and the 
other, if possible, that of the usual medical attendant 
of the defective. 

If the defective is not an idiot or imbecile, but merely 
feebleminded, the certificate must also be signed by 
a judicial authority. 

An order given by a judicial authority operates 
within 14 days (or if the defective is in a place of safety, 
within 21 days), lasts for one year, and can only be con- 
firmed by the Board of Control. After the second year 
the continuance is in periods of five years. If the defec- 
tive is under the age of 21, the case must be reconsidered 
by the visitors within three months of the defective's 
attaining the age of 21 years. 

Orders can be made by the judicial authorities or 
courts apart from the instance of parent or guardian 
or officials of local authorities in the case of defectives 
coming up for offences rendering them liable to im- 
prisonment or detention, and in cases where the petition 
is presented by a relative or friend, or local authority 
or official. 

If the judicial authority makes an order, the defective 
is placed under control or guardianship. 

Establishments for Control. — Establishments for 
control are of the following kinds (see Mental Deficiency 
Act, Section 71) : — 

(1) State Institutions are those for defectives of 
dangerous or violent propensities established by the 
Board under the Act. 

(2) Certified Institutions are those in respect of which 
a certificate has been granted under the Act to the 
managers to receive defectives therein : they include, 



42 METHODS OF DEALING WITH DEFECTIVES 

subject to the provisions of the Act, any premises pro- 
vided by a Board of Guardians and approved under 
the Act. 

(3) Certified Houses are houses in which defectives are 
received by the owner thereof for his private profit, and 
in respect of which a certificate has been granted under 
the Act. 

(4) Approved Homes are premises in which defectives 
are received and supported wholly or partly by volun- 
tary contributions, or by applying the excess of payment 
of some patient for or towards the support of other 
patients in a house in which defectives are received by 
the owner thereof for his private profit and which has 
been approved by the Board under the Act. 

Visiting of defectives in establishments is allowed for 
the nearest relative at least every six months, unless 
such visits are found by the superintendent to be de- 
trimental to the defective. 

A definite classification of cases according to some 
recognised scale is important, because there is need for 
institutions to specialise in the different grades of defect, 
for the purpose of economy and facility of administration. 
By such specialisation great economy in the teaching staff 
and apparatus can be effected, as well as in financial 
arrangements. This has been the experience in America. 

American Methods. — The visits of certain of the 
Commissioners to other countries, and especially that to 
America, the result of which is embodied in a special 
volume of their report, only served to emphasise the 
value of lifelong care and of the farm colony system, 
with a separation of the various grades of defect. 

In America the institutions are of a high grade of 
efficiency, and are worked very economically. The 
earlier ideas were that the feebleminded could be brought 
to earn their own living, but these had to be given up, 
and lifelong care was found to be much more desir- 
able from all points of view. The Commissioners were 



AMERICAN METHODS 43 

impressed by the large size of the institutions, a charac- 
teristic rather advantageous than otherwise since the 
cases could be divided into three departments, and could 
be transferred from one department to another if 
necessary. The three departments were (1) the Custodial 
for the lowest grade idiots ; (2) the School for the higher 
grade children; and (3) the Industrial for higher grade 
adults. 

It is certainly better to separate cases first into classes 
according to the sex and age, and then to divide them 
according to the grade of intellect and to their power of 
working, without paying too much attention to their power 
of doing school work, which is almost the least important 
part of their training. The Waverley establishment, Bos- 
ton, Mass. (the Annual Reports of which are well worth 
study) is well described by Miss Dendy in her article 
" Workers or Wastrels " in the Charity Organisation 
Review of November, 1909. At this institution there 
were then about 1,400 (and in 1917, 1,778) people of 
both sexes and all ages from six to sixty. The colony 
is state-supported. All, but the men and boys who are 
physically incapable, are employed in useful work, which 
consists of road-making, coal-loading, gardening, farm 
and house-work, and also reclaiming swampy ground. 
Beginning with very simple tasks to train the senses, 
mental defectives are usually able to turn to useful work 
even though they cannot make the least progress in 
school. A farm colony for the older men is attached to 
Waverley, and here 250 men live and work contentedly, 
while the two institutions help to support one another 
by exchanging farm and industrial produce. 

Dr. Fernald, the Superintendent, in a paper on " The 
Growth of Provision for the Feebleminded in the 
United States," published in Mental Hygiene, vol. 1, 
No. 1, January, 1917, gives the following plan : — 
(1) A Parent Institution fairly near to a large 
centre for (a) the young, (b) the bed-ridden and 



44 METHODS OF DEALING WITH DEFECTIVES 

infirm, (c) the custodial, (d) the new admissions 
for classification; with (2) Colonies twenty to fifty 
miles away on good land — some of these colonies may 
be temporary to clear areas of land and some permanent ; 
and (3) Measures for After-care of the best cases who 
may be able to live in their own homes or be boarded 
out. 

The results of the Newark State Custodial Home for 
Feebleminded Women with its object " to detain women 
of a child-bearing age in order to prevent the propaga- 
tion of persons of feeble mind with its attendant evils 
to the community " were particularly good. " About 
half the cases admitted to this institution were decidedly 
imbecile or idiotic, the other half being high-grade 
imbeciles, or young women whose mental defect was so 
slight that on casual observation it would not be 
evident." 

In the United States the provision for the feebleminded 
and epileptic under State care has risen very rapidly. 
In 1890, 4,001 were cared for, in 1904, 15,599, and in 
1916, 34,137. Dr. Fernald points out (1) that this rise 
is due to increased knowledge and ascertainment and not 
to increase of feeblemindedness and epilepsy; and (2) 
that the provision, even in Massachusetts, which is 
caring for nearly three times as many per 100,000 as the 
country at large, only a small part of what should be 
done is being done. 

Finance. — The cost of caring for cases in an institu- 
tion is a serious item. The Commissioners, dealing 
with pre-war prices, estimate that for the 66,509 
cases " needing provision " the cost would be 
£1,175,802 under their scheme, meaning an increase 
of £541,492 over the amount spent then on the care of 
the mentally defective : but they point out that some 
of this increase would be borne by the parents and 
friends of the cases dealt with. They think that the 
past methods were abnormally wasteful, being founded 



FINANCE 45 

on entirely wrong principles, so that much could be 
saved by reorganisation, the adoption of uniform 
methods, and by the different " colonies " and 
" hospitals " specialising in the different grades of cases, 
and in this way being able to work more economically. 
The accounts of institutions should be audited, and a 
system of collection of contributions from relations 
enforced. 

With regard to the cost of maintenance at colonies or 
institutions, the pre-war capital amount was estimated 
as from £100 to £120 per head. Now, however, and 
probably for some time to come, this should be taken 
as at least 200 per cent. more. The pre-war cost for 
maintenance exclusive of capital was reckoned generally 
at from eight to nine shillings per week. At the Sandle- 
bridge Colony the gross cost for maintenance for the year 
ending 30th September, 1914, including teaching, but 
excluding rent charge and depreciation, was £23 18s. 2d. 
The cost for the year ending in the same month of 
1918, with a monthly average of 290, was £36 4s. 8|d., 
an increase of £12 6s. 6|d. In common with other man- 
agers of institutions faced with similar difficulties, the 
Governors found it necessary to meet this increased cost 
by an addition to the charge for the maintenance of 
"patients. 

It will still be necessary to provide for supervision and 
care for many children and adults who will, for one 
reason or another, not be brought to special schools, or 
have petitions presented for them; such are children 
under seven awaiting admission to special schools, 
children excluded from special schools and not provided 
for by institutions or other care. One knows from 
experience how many cases there are in need of such 
care, and unable to obtain it. 

As a physician, I see constantly, either amongst out- 
patients or elsewhere, defective children who have come 
under no control, and do not appear likely to do so. 



46 METHODS OF DEALING WITH DEFECTIVES 

Notification of these cases, and requests for control, do 
not have much effect, even though the parent may be 
anxious to be relieved of the burden of caring for the 
child and may be forced by this burden to neglect the 
other children. I am impressed by the great need for 
searching out defectives in every area, and having them 
upon a register, so that they can be found when oppor- 
tunities for ensuring their care may be provided. This 
need has also been expressed by other persons who have 
had to administer the Act (see p. 49). 

Later Experiences. — In order to illustrate the work- 
ing of the Mental Deficiency Act, and to show the 
difficulties that have arisen, it is interesting to note a 
few of the points raised at a Conference on its 
Administration, which was held at the Guildhall in 
February, 1918, under the auspices of the Central Asso- 
ciation for the Care of the Mentally Defective. Since 
most of the different classes of individuals concerned 
in the actual administering of the Act were present and 
took part in the discussions, the report is of great 
interest. 

Accommodation. — Clear evidence was given to show 
that much more accommodation is at present badly 
needed. Mrs Hurle, speaking of experience with the Local 
Authority in Somerset, stated that " the existing accom- 
modation is totally inadequate and much of it wholly 
unsuitable." She went on to say that the financial 
clauses of the Act do not provide the necessary funds. 
Alderman Parry said that in Monmouthshire, out of 600 
cases only 6 had been sent to institutions, and the bad 
cases were left on their hands. Sir Harcourt Clare, 
Clerk to the Lancashire Asylums Board, said that the 
certified institutions managed by the Associations and 
bodies other than the Local Authorities are full, and that 
the provision of certified institutions for defectives by 
the Local Authorities seemed for the present to be 
practically impossible. He stated that they had at 



ACCOMMODATION 47 

present 500 cases in institutions and 600 on their books 
waiting for accommodation, and not a single bed to be 
found for any of them in the whole of Lancashire. 

He went on to say that the only way for the present 
was to have premises set apart and certified as institu- 
tions in the existing workhouses; that this had been 
done to some extent already. Mr. Cole, Chairman of 
the Middlesex Deficiency Committee, spoke very strongly 
in favour of this course, basing his opinion on the 
experiences gained from the Brentford Institution. Mr. 
Waugh, Chairman of the Bradford Committee, was of 
the same opinion. It must be clearly understood, how- 
ever, that such arrangements should only be temporary, 
and that such premises should be replaced by separate 
institutions as soon as possible. Dr. Coupland, Medical 
Superintendent of the Royal Albert Institution, said that 
the use of such premises should be a war measure only. 

The whole question has been one of finance. The 
war has crippled temporarily the development of con- 
structive work. 

There is, however, need for more local thought and 
effort. Mr Leslie Scott, K.C.,M.P., Chairman of the Con- 
ference, showed how much unevenness of constructive 
work there had been in different areas, informing the 
Conference that, of the £150,000 available in one year 
for spending on the mentally deficient, only £60,000 had 
been spent, because the amounts of work done by 
different Local Authorities varied so much, while the 
allotment made by each authority had been on a popu- 
lation basis. Thus some had spent their allotment, but 
others had not. 

And yet there is immense need of spending money on 
the work, because such spending is really a great 
economy to the nation. A glaring example of how it 
is an economy was given by Dr. Tredgold, who said 
that the Clerk to a Board of Guardians had told him of 
a defective, who had been an inmate of a workhouse for 



48 METHODS OF DEALING WITH DEFECTIVES 

many years, and had cost the Board £1,600. He went 
on to say that the total bill to the nation must be 
enormous at present, when one considers the cost of legal 
proceedings, maintenance in pensions, etc., poor-law 
relief, and the officials employed in the work. 

The Conference was so impressed with the urgency of 
the need for more institutions that they passed resolu- 
tions urging that the work be carried on even in war- 
time, and that the financial limitations on Local Authori- 
ties who are administering the Act with vigour should 
be removed. 

Duties of Local Authorities. — Mrs. Hurle, dealing 
with the duties of Local Authorities under the Act, 
brought out several points of difficulty. 

The clause " from birth or from early age," in the 
definitions of the various kinds of mental deficiency, and 
the word " neglected " in the statement of the subject 
to be dealt with, have given rise to much difficulty, 
because either the early history of the case may not be 
available, or a case cannot be proved to be neglected, 
and in this way cases really needing control may avoid 
it. Obviously, both these are weak points of consider- 
able importance. 

A further one concerns the defective women having 
illegitimate children. These women are most urgently 
in need of control, but cannot be brought under such 
unless they are in receipt of Poor-Law relief at the time 
of pregnancy or at the birth of the child. 

Mrs. Hurle gave examples which are worth noting in 
full. 

" A. B., a feebleminded lad of 25, was committed for trial at the 
Court of Quarter Session. The Local Authority arranged to send 
him to a Training Institution in the event of the Court handing 
him over to them. The medical evidence before the Court showed 
that he was mentally weak and was mentally degenerating, but 
no evidence could be produced to show that the defect had existed 
* from birth or from early age. 5 He was sentenced to six months' 
imprisonment. It is easy to see that such a case as this will go 
on being an increasing burden to the community." 



ASCERTAINMENT 49 

" C. D., a weakminded, facile woman of 30, has twice been in 
an asylum, has had three illegitimate children, and cohabits with 
her stepfather. She could not be dealt with under that Act, there 
being no evidence of early imbecility. This woman is free to 
reproduce her species at the expense of the community." 

One can readily supply examples where neglect is 
difficult to prove, and yet where training and control 
are badly needed but not in force because the parent 
is unwilling. 

Mrs. Hurle also shows that the clause " consent shall 
not be deemed to be unreasonably withheld if withheld 
with the bona-ftde intention of benefiting the defective," 
is a cause of difficulty and needs amendment. Further, 
that the time limit of fourteen days for the execution 
of an order (see p. 41) after it has been made is often 
a cause of hardship, or highly inconvenient because suit- 
able institutional accommodation may not be at once 
available. The Court should therefore have power to 
extend this period, if necessary. 

Ascertainment. — Miss Evelyn Fox, Hon. Secretary 
to the Central Association, drew attention to the 
extreme importance of care of defectives in any area, 
arguing that the reason why many area authorities were 
not impressed by the importance of providing care was 
because they had no reliable information of the number 
and needs of the defectives in that area. This was 
borne out also by Mr. Leslie Scott, who emphasised the 
need of ascertainment in the strongest possible manner. 

There is no doubt that if the true facts and figures 
relating to the defectives in any area are brought clearly 
before the authorities charged with providing for them, 
those authorities will see the burning need for activity, 
and begin to adopt proper measures. 

The ways and means of ascertainment and notifica- 
tion under the Act are rather complicated, being divided 
amongst various authorities who, though urged to co- 
operate (see p. 26) may not do so. Seeing how very im- 
portant such work is, the need for more definite fixing 



50 METHODS OF DEALING WITH DEFECTIVES 

of responsibility and more complete measures of ascer- 
tainment is great. Voluntary associations can help in 
these matters. 

With regard to the visiting of defectives at their houses 
by voluntary associations, Miss Fox gave instances of 
how representatives of these societies are welcomed by 
the parents, one association having 900 cases under 
supervision, and in only 10 to 15 instances was any 
resentment shown to the visitor. 

Local Education Authorities. — The work of the Local 
Education Authorities under the Act was discussed by 
Dr. H. B. Brackenbury, President of the Association of 
Education Committees. 

He gave the duties as : — 

(1) Discovery, (2) Education, and (3) Notification. 
Under (1) he pointed out that defective children should 
really be discovered before the age of seven, and that 
Education Committees should take a great share in 
discovery and notification of such cases. He pointed 
out the difficulty of providing special schools in all 
except the thickly populated areas, and gave instances 
where different education authorities had combined to 
form joint schools. 

Mr. J. L. Holland, Director of Education for North- 
amptonshire, spoke of special schools and special classes, 
saying that with a population of 62,000 within a radius 
of three miles a special school was justified. He 
emphasised the difficulties met with in special day 
schools, and the advantages of residential schools in 
comparison. 

Sir Harcourt Clare was very emphatic in stating that 
the Board of Control should have the whole of the 
control in their hands, instead of its being divided with 
or given to the Education Authorities for certain age 
periods. 

The whole question of the position of the special 
schools needs careful consideration. There is no doubt 



LOCAL EDUCATION AUTHORITIES 51 

that, for most high-grade feebleminded children, and for 
all lower-grade defectives, a residential school or a 
colony is much better than a day school; special day- 
schools provide training, but they do not provide super- 
vision throughout the whole day, and do not remove the 
child from outside influences which cannot be controlled. 
In addition they only cover an age-period, and thus lead 
to interruptions in continuous care; further, it is very 
much better for a child who is going to an institution to 
begin there at as young an age as is possible. 

The Incorporated Lancashire and Cheshire Society for 
the Permanent Care of the Feebleminded, from the ex- 
perience of practical working with the Sandlebridge 
Colony, have also drawn the attention of the Board 
of Control to the following three points, and to the need 
of provision to meet them : — 

(1) If a Judicial Authority is considering a petition in 
the case of a child about to be withdrawn or discharged 
from a special residential school, full evidence from the 
Education Authorities maintaining him, and from the 
officers of the school in which the child has been, should 
come before the Judicial Authority, as well as the 
information at present submitted. 

(2) That there is need for a regulation as to who is 
to be responsible for the maintenance of a defective from 
the age of sixteen, during the interregnum between the 
responsibility of the Education Authority and the con- 
sideration of the case by the Judicial Authority. 

(3) That all institutions for mental defectives should 
be certified under the Education Acts, as well as under 
the Mental Deficiency Act, and so be able to provide 
continuous care from childhood upwards in the same 
institution and under the same officers. 

Sandlebridge is certified under both authorities, and 
the continued home life and atmosphere which it is the 
aim of the management to preserve is therefore made 
possible. 



52 METHODS OF DEALING WITH DEFECTIVES 

It is only under such conditions that it is possible to 
provide adequately for the happiness of the feeble- 
minded. 

The age of sixteen is a very bad time to break the 
continuity of the feebleminded child's life, and to re- 
move him from his familiar surroundings and trusted 
teachers. At that age it is not easy to adapt him to a 
new life, and to give him the same confidence and trust 
in those who look after him. Also from the point of 
view of the teacher or superintendent, it is disheartening 
to have cases for whom much care and trouble has been 
taken removed as soon as they reach a certain age. After 
twenty years' experience, the Governors of the Sandle- 
bridge Institution are most emphatic in stating that the 
lifelong care should be in the same institution and, as 1 
far as possible, under the same officers. 

Summary. — One can sum up by saying that residen- 
tial care is by far the best remedy, and that special 
day-schools can never be a really effective measure for 
dealing with feebleminded children, though they are very 
necessary and a great advantage at present, because 
there is not nearly enough residential accommodation. 

Thus it can be seen that there is still a great deal to 
be done in ascertainment, in construction, and in pro- 
paganda work. It must be noted that the principles 
upon which such work is based are : — 

(1) That all mentally defective persons, who are 
really incapable of earning their living when left to 
their own devices, should receive from the State such 
special protection as may be suited to their needs. 

(2) That the community should be protected from 
the harm that may be done by allowing feebleminded 
persons to be free to follow their own inclinations or to 
come under the control of ignorant or unscrupulous 
individuals. 

(3) That the different circumstances and different 
needs of the various cases necessitate the provision of 



SUMMARY 53 

different methods suitable to the several types of case 
and not the provision of any one fixed method. 

(4) That such cases should be dealt with primarily 
on the ground of their mental defect, and not, as 
hitherto, on the ground of their poverty, their violence, 
or their crime. 

The passing of the Mental Deficiency Act has made 
possible a great advance in caring for mental defectives. 
If much is to be done for them, if they are to be made 
self-supporting in any degree, it is necessary that they 
should come under control early. If taken as young 
children they are more amenable to discipline, more able 
to learn useful occupations, good habits can be taught, 
and they can be guarded from dangers and temptations. 

Perhaps one can justly say here that most of the 
feebleminded never become mentally anything else but 
children and very unintelligent children at that, though 
it must not be forgotten that they develop in physical 
strength, and may attain with puberty the instincts 
and passions of the adult. 

I once visited and examined at their homes some 
thirty mentally deficient children, who had been rejected 
from the special schools in Manchester for various 
reasons. 

Many of them were a source of endless trouble and 
annoyance to their parents, who would have been only 
too glad to obtain some relief from their burden ; others 
were jealously guarded and hidden away by doting 
mothers, who lived on, hoping for some improvement, 
grudging no effort and never admitting that the child 
was a source of immense anxiety and care. 

Parents, however fond, do not as a rule live long 
enough to be lifelong guardians, and also they, as 
persons who often meet with little success in controlling 
the child, are not likely to be able to control the adult. 
Lifelong care of the feebleminded person, strengthened 
by legal powers of detention in an institution if neces- 



54 METHODS OF DEALING WITH DEFECTIVES 

sary, is therefore of paramount importance, and we must 
hope that the well ordered scheme brought out by the 
Board of Control will gradually develop into an effective 
reality. 

Criticisms of these ideas abound, short-sighted criti- 
cisms based on the ground of expense, and of the use- 
lessness of wasting time and energy on the training 
of these unfortunates. But we must realise that money 
spent in this way is well laid out, and at the same time 
that training, properly developed, can lead to profitable 
work and production. 

It is not possible to " gather grapes of thorns, or 
figs of thistles " : yet if the thistle is not kept within 
bounds and prevented from spreading its kind broad- 
cast, it may do untold harm and involve a far greater 
expenditure of time and money than if efficient measures 
for controlling it had been taken from the first; and, 
to carry the allegory further, even a thistle may be of 
some small value if properly utilised. 



CHAPTER III. 

PHYSICAL CHARACTERISTICS. 

Classification of Feebleminded Children. — If we 
classify cases of mental deficiency according to their 
causation we can divide them into two great classes — 

(1) Primary (Genetous), which form 90 per cent., and 

(2) Secondary, Accidental or Acquired, which form 10 
per cent, of the whole. The term Genetous as used by 
its originator, Dr. Ireland, includes all primary or 
developmental cases as distinguished from those of 
acquired defect. 

On the other hand, if we classify cases according to 
their physical characteristics, we find that, though 
feebleminded children may belong to one of the six 
special types described in Chapter VI., the great majority 
do not. At first sight they appear very little different 
from ordinary children. There is always a tendency to 
exaggerate the importance of definite types and definite 
deformities, and it is very necessary to appreciate fully 
the fact that the majority of feebleminded children show 
no constant physical characteristics by which they may 
be recognised.* 

The six special types referred to are (1) the Cretin, 
(2) the Mongol, (3) the Microcephalic, (4) the Paralytic, 
(5) the Inflammatory, and (6) the Hydrocephalic ; these 
can be recognised by their physical characteristics. 

In considering the statistics relating to mentally 

* For educational and institutional purposes a classification based 
on the mental capacity is necessary. See p. 87, and Tredgold, 
p. 167. 

55 



56 PHYSICAL CHARACTERISTICS 

deficient children, it is important to distinguish between 
those coming under observation at a hospital and those 
examined and found suitable for admission to a special 
school or an institution for high-grade cases. The 
former include all grades of mental defect and the 
latter feebleminded children only. Of 100 consecutive 
cases of mental deficiency (all grades) under my obser- 
vation at the Manchester Children's Hospital, Pendle- 
bury, 7 were cretins, 16 mongols, 11 microcephalics, 
7 paralytic, 3 inflammatory, hydrocephalic, and 2 
followed measles. 

Dr. Still, taking 350 cases, found that 10 or 2.8 per 
cent, were cretins, 77 or 22 per cent, mongols, 22 or 6 
per cent, microcephalics, and 26 or 7 per cent, paralytic. 

On the other hand, of 904 cases examined for admis- 
sion to the Manchester Special Schools 8 or 0.9 per cent, 
were cretins, 11 or 1.1 per cent, mongols, 5 or 0.55 per 
cent, microcephalic, 19 or 2 per cent, paralytic, 5 or 
0.55 per cent, hydrocephalic, and 1 or 0.1 per cent, 
inflammatory. 

Dividing these cases into the 784 who were fit for 
admission and the 120 who were rejected as too defective, 
we find that of the 784 cases admitted (some of them on 
probation) 6 or 0.7 per cent, were cretins, 4 or 0.5 per 
cent, mongols, 5 or 0.5 per cent, microcephalics, 9 or 
1.2 per cent, paralytic, and 2 or 0.25 per cent, 
hydrocephalic. 

Of the 120 cases rejected as too defective 2 or about 
2 per cent, were cretins, 7 or 6 per cent, mongols, none 
microcephalic, 10 or 9 per cent, paralytic, 3 or 2 per 
cent, hydrocephalic, and less than 1 per cent, 
inflammatory. 

These figures can be tabulated as follows : — • 




Plate II. Feebleminded Children of the Ordinary Type. 



PHYSICAL DEFECTS 57 





TABLE I. 










Hospital Cases. 


Feebleminded 






(All grades.) 

ttO 

1 $ 

Hi OQ 


1 
I 


"73 

a 


ai 

S3 

9 




Per cent. 


Per cent. 


Per cent. 


Per cent. 


Per cent. 


Cretins 
Mongols 


... 7 
... 16 


2.8 
22 


2 
6 


0.7 
0.5 


0.9 
1.1 


Microcephalics 
Paralytics 
Hydrocephalics ... 
Of no special type 
Epileptic 


... 11 
... 7 
... 0.0 

... 54 


6 

7 

0.3 
50 
6 




9 

3 

59 

20 


0.6 
1.2 

0.25 
91 
5 


0.55 
2 
0.5 

7 



These figures show conclusively that the special types 
and notably the mongols and paralytics tend to be of 
low grade. Paralytics, however* are often able to learn 
if treated. Cretins, being improvable, often come 
under notice first as hospital cases. The figures also 
show a more important fact, namely, that 91 per cent, 
of the children suitable for treatment as feebleminded 
are not of any special type, even when epileptics are 
put into a separate class. 

Physical Defects. 

(1) Stigmata of Degeneration. — The physical 
stigmata of degeneration are common in feebleminded 
children and in other children with a neuropathic in- 
heritance, but it is well to state at the outset that too 
much importance must not be attached to these deformi- 
ties. They do not necessarily mean that there is any 
tendency to mental deficiency, and they are often pre- 
sent in ordinary children. Also their presence or absence 
does not give any indication of the degree of mental 
defect. They are, however, more marked, more 
numerous, and more often found in feebleminded than 
in ordinary children. Such stigmata are developmental 
in origin, and are present though not always evident 
at birth. 



58 PHYSICAL CHARACTERISTICS 

(a) Defects in the size and shape of the Head. — Such 
defects are estimated much more exactly by contour 
measurements than by judging from the appearance or 
feeling with the hand, but for ordinary purposes the 
greatest circumference taken with a tape-measure is 
enough. When there has been an early paralysis, the 
skull on the side on which the brain is affected often 
shows a marked diminution as compared with the other 
side (Petersen). Ashby and Shuttle worth both com- 
ment on the fact that deficient occipital development or 
poor formation of the back of the head is common in 
the feebleminded. Other writers state that a frontal 
deficiency is common also. However, it is not possible 
to form an idea of the local or small abnormalities of 
the brain from external skull measurements, because the 
shape of the skull is not always a true indication of the 
shape of the brain beneath. Abnormal development or 
undevelopment of one part of the brain may simply 
mean that the neighbouring parts of that organ are dis- 
placed, and not that the skull is altered in shape. On 
the other hand the grosser defects certainly make a 
difference to the size and shape of the skull ; this is well 
shown in microcephaly, where the very small brain 
allows the skull to close up early, giving the diminutive 
head that is characteristic of the condition. 

The detailed examination of the heads of 200 feeble- 
minded children by the methods described in Appendix 
II. gave the following results : — 

The most common defects of the heads of feeble- 
minded children are smallness and asymmetry. The 
normal circumference of the head of a school child should 
be over 20 inches, and 34 per cent, of the cases had heads 
less than 20 inches in circumference, while 26 per cent, 
had asymmetry. Taking the external auditory meatus 
as a fixed surface mark, the posterior or occipital part of 
the skull was found to be much smaller in the feeble- 
minded than in normal children. This deficient occipital 



HEAD MEASUREMENTS 59 

development was most noticeable in the cases with 
poorest mental powers (see Table V). The value of the 
measurement round the greatest circumference of the 
head is that it helps to show poor development of either 
occipital or frontal regions. 

The average cranial capacity obtained by multiplying 
the length, height, and breadth together (an inexact 
method but one which gives approximate results) showed 
that 20 children of normal intellect gave an average of 

3105.5 c.c, 20 feebleminded classed as " Good " 

2969.6 c.c, and 20 feebleminded classed as " Bad " 
2723.3 c.c. 

As will be seen from Table II., the averages of the 
head measurements did not differ so much as one might 
have expected, this being especially so in the case of 
the maximum circumference. This only serves to 
emphasise the point that the majority of the feeble- 
minded do not show any grossly marked physical 
deformities or differences from ordinary school children. 

Therefore the common cranial defects are those of 
asymmetry or irregularities in the conformation of the 
skull rather than marked diminution of capacity, though 
there is a certain tendency to diminished capacity cor- 
responding to the degree of mental deficiency. 

Description of Plate III. 

1, 2, and 3. Tracings of the head of E. C, aet. 11 years, a child 
of average intelligence. An example of a well-shaped though 
small head. Inside tracings 2 and 3 are tracings from a feeble- 
minded child of approximately the same age. 

4. Tracing of the head of E. R., set. 9 years, a feebleminded 
child, who had suffered from a right hemiplegia five years ago. 
An example of the rounded, small head. The right-sided hemi- 
plegia and the smaller left side of the skull are correlated. The 
middle line in front and behind was carefully marked in all 
tracings. 

5. Tracing of the head of H. C, aet. 12 years. An example 
of an asymmetrical head. 

6. Tracing of the head of C. B., aet. 11 years. An example 
of marked rickety deformities. 

The head measurements in each case were : — 



60 



PHYSICAL CHARACTERISTICS 




3. ■■' 6. 

Plate TIT.— Tracings to show Abnormalities of the Head as found m the 
Feebleminded (for description see p. 59). 







Plate IV. Abnormalities of the External Ear. 



EXTERNAL EAR 61 





Tracings 


Tracing 


Tracing 


Tracing 




12&3. 


4. 


5. 


6. 


Circumference 


20 in. 


18i in. 


21 in. 


20iin. 


Basion to nasion over 










skull 


15 in. 


■ — 


15 in. 


14 in. 


Bitragal arc 


11 in. 


— 


13£ in. 


13 in. 


Antero-posterior diam. 


18 cm. 


16.5 cm. 


19.5 cm. 


17.7 cm. 


Occipital segment ex- 










ceeds frontal by ... 


If in. 


equal 


equal 


fin. 


Bilateral diameter ... 


13 cm. 


13 cm. 


13.8 cm. 


13.7 cm. 


Right segment exceeds 










left by 


equal 


fin. 


lin. 


iin. 


Height 


12 cm. 


11.5 cm. 


13.7 cm. 


11.5 cm. 


Bitragal diameter 


11 cm. 


10.5 cm. 


11.5 cm. 


12.2 cm. 


Distance from nasion 










to basion 


13.2 cm. 


13 cm. 


14.5 cm. 


13.5 cm. 



(b) Deformities of the External Ear, — The normal ear 
is seen in PL IV., No. 5, and, since it is originally 
developed from six processes or tubercles, it is easy to 
see that signs of separation may remain or that some 
part may be deficient. The six tubercles form what are 
known as the cms helicis, the helix, the antihelix, the 
tragus, the antitragus, and the lobule. The tragus 
and antitragus as respectively the parts just in front and 
just behind the opening of the ear. The lobule is the 
soft fleshy dependent part below the opening : the crus 
helicis, the helix, and the antihelix together form the 
Upper and cartilaginous part above the opening, and the 
whole of the external ear outside the skull is known as 
the pinna. 

Description of Plate IV. 

I. — Defective left ear of T. H., showing deficiency of the lobule, 
absence of the fossa?, maldevelopment of the helix, and a tendency 
to reversion to the pointed ear. The right ear was only deficient 
in the shape of the lobule. 

II. — Defective ear of A. C, exhibiting general deformities in 
shape, but chiefly remarkable as showing a tendency to lobulation. 

III. — Defective ear of G. M., showing general smallness with 
absence of the lobule. 

IV. — Defective ear of J. J., an example of the large protruding 
ear with a heavy lobule. 

V. — Normal ear (Keith's " Embryology "). 

VI. — Defective ear of R. H., showing a deficient lobule, a 



62 PHYSICAL CHARACTERISTICS 

deficient helix, fusion of the helix, antihelix and antitragus, and 
a general rounding. 

VII. — Defective ear of E. M., showing deficiency of the upper 
part of the pinna. 

VIII. — Defective ear of a Mongolian imbecile, showing small- 
ness, general rounding, and crumpling. The upper part of the 
pinna overhangs in a characteristic manner (see Plate IV., No. 8). 

IX. — Defective ear of A. R., showing shallowness of absence of 
the fossae, deficiency of the tragus and antitragus, and general 
malde velopment . 

An eminence known as Darwin's tubercle is to be seen 
at the upper angle, and this corresponds to the tip of 
the ear in the lower animals. In man the ear is turned 
over so that the tip points forwards and downwards. 

Defects of the external ear include absence or 
deficiency of the lobule, irregularity or increased depth 
of the fossae, and deficiencies in shape or size of the whole 
pinna such as excessive breadth, diminished height, 
smallness and protrusion. Some authors describe more 
than twenty different kinds of abnormalities, but these, 
though interesting, are not of sufficient importance to be 
dealt with more fully here. The mongol ear is the only 
deformity that goes uniformly with one special type of 
deficiency. 

Defective ears were found in 32 per cent, of my cases, 
lobular defects being by far the most common. These 
lobular abnormalities are very common in ordinary 
children and are a very slight form of defect. The 
others are not so common and are more marked stigmata 
of degeneration. An unusual prominence of Darwin's 
tubercle is sometimes seen, but it is hardly of the same 
significance as the other abnormalities of the external 
ear. 

It is not very uncommon to find the right ear different 
from the left, some children having a perfectly formed 
ear o n one side and a defective one on the other. 

(c) Deformities connected with the Eyes. — Adherent 
epicanthic folds are everted ridges of skin starting from 
below the eyebrow and continued round the internal 



EYES AND PALATE 63 

angle of the eye. They are generally symmetrical, but 
may be present only on one side. Epicanthus is accentu- 
ated, but not caused, by depression of the bridge of 
the nose, and these folds can be obliterated by pinching 
up the skin over the bridge of the nose; but they im- 
mediately return when the skin is released. They must 
not be confused with the plica semilunaris which is on 
the conjunctiva and not on the eyelid. 

Epicanthus is not a very common defect. It occurred 
in 8.79 per cent, of my cases, and in 1.37 per cent, of 
the ordinary school children examined by Dr. Warner. 
Squint or strabismus is such a common condition in 
children that it can hardly be regarded as a stigma of 
degeneration. A condition known as nystagmus is not 
uncommon. Nystagmus is really a trembling of the 
eyes, which move very rapidly from side to side, especi- 
ally if the child tries to turn them in any one direction. 
The condition is not likely to improve much. 

(d) Deformities connected with the Palate and Jaws. 
— Certain deformities of the palate are stigmata of 
degeneration, but others are acquired. Like the other 
stigmata of degeneration the developmental deformities 
of the palate have received an undue importance, for if 
the palates of any unselected group of ordinary children 
are examined, quite a fair proportion will be found to be 
abnormal. However, there are certain deformities which 
are more common amongst the mentally deficient, and 
elaborate classifications of these can be found in books on 
mental diseases. Petersen gives eight different forms. 
He found such defects in 82 per cent, of idiots, imbeciles, 
and feebleminded, in 76 per cent, of epileptics, and in 
80 per cent, of the insane. 

There are two main forms, the V-shaped and the 
highly-arched palate, and there is often quite a big 
margin of ribbed and roughened gum-like tissue extend- 
ing inwards from the teeth to where the high, narrowed 
arch of the palate commences. 



64 PHYSICAL CHARACTERISTICS 

Abnormalities of the palate occurred in my cases more 
often than any of the other stigmata of degeneration, 
being found in 67 per cent., but, as we have said, they 
are not uncommon in ordinary children and are not 
always of congenital origin. 

Cleft palate is not a stigma of degeneration, and is 
as rare amongst the feebleminded as amongst ordinary 
children. 

As we shall see later, deformities of the palate apart 
from cleft palate do not have much effect on speech, 
partly because the tongue is such a supple organ that 
it can adapt itself to a highly arched palate. 

Prognathism or protruding jaw is described as a stigma 
of degeneration. 

(e) Other Stigmata. — Another not uncommon stigma 
is an incurvation of the terminal joint of the little finger 
with the concavity of the curve towards the third finger. 
Other peculiarities mentioned on page 67 are many of 
them stigmata also. 

Comparison of numbers of feebleminded with ordinary 
children shows that the former exhibit the stigmata of 
degeneration much more often and in greater number 
than do the latter : thus mentally deficient children 
often have a combination of one or two or three 
stigmata, and ordinary children may have a single 
stigmata, but have them less often and the combined 
stigmata much less often than do feebleminded children. 

(2) Heights, Weights and General Physical 
Characteristics. — Heights, Weights, and Head Measure- 
ments. — It will be seen from Table II. (p. 66) that the 
average heights, weights, and head measurements of 181 
feebleminded children, of ages ranging from 6 to 14 were 
smaller than those of ordinary children. 

The table is divided into three parts, A, B, and C, 
and the children classified according to their ages into 
three groups, so that comparisons could be made with 
the tables given by Professor Hay and Dr. Mackenzie 



HEIGHTS AND WEIGHTS 65 

in their reports on Aberdeen and Edinburgh school 
children. B represents the corresponding part of Dr. 
Mackenzie's table, and C the amount of the difference 
between the averages in A and B. 

It will be seen that in all cases the average measure- 
ments are smaller in the feebleminded, and that the dis- 
parity increases with age. Apart from their inherited 
powers of development and growth, the feebleminded 
suffer from many disadvantages, for they are more liable 
to disease and do not have the same opportunity to 
join in games or physical exercises as do ordinary 
children. There is often a great improvement in the 
physique and weight soon after the child has begun such 
exercises and games as are used at the special schools 
or the colonies. Nevertheless, the boys and men at 
Sandlebridge are noticeably small in physique. The 
girls are also small but differ in that they, not uncom- 
monly, become very fat as they grow older, and this in 
spite of good hard work. This obesity, which adds to 
their ungainliness, may in some cases be reduced by 
thyroid extract (Mcllraith). 

The circulation is often very poor, so that cold hands 
and feet and chilblains are common, and it is very 
necessary to keep this in view when considering clothing 
and exercise, and to guard against it in cold weather. 
Taylor and Pearce found that organic heart disease is 
relatively more common in feebleminded children and is 
a causative agent in their downward course, and that 
the pulse is often irregular. They point out the advan- 
tages to the mind and body of treatment directed to im- 
proving the circulation. 

Supernumerary auricles and fingers and other miscel- 
laneous congenital abnormalities, such as harelip and 
cleft palate, should not be included under the stigmata 
of degeneration, and though interesting from a develop- 
mental and surgical standpoint, they are not especially 
common amongst the feebleminded. 
E 



66 PHYSICAL CHARACTERISTICS 






CM r-l CM (M <M CM 



11 








































OS 

CD 

CO 

b- 


CO 


CO 

b- 


q 
t-* 


co 


co 

©J 

CO 

fc- 


CO 
CO 


<* 

CO 
CO* 

b- 




CO 

CO 

OS 

b- 


© 

CO 

b- 


co 

00 

CO 

fc- 




b- 


CM 

oi 


CO 
CO 

CM 


2 


K3 




co 


CO 


b« 

co 


5 


CO 
CO 




co 


CO 


CO 
<M 


CO 

T— 1 


co 


1— 1 


CO 




OS 
«3 


CO 
b- 


o 

b- 


o 
o 


co 


CO 


CO 


CO 


co 


CO 


^ 


CO 


^ 


<* 


-# 


<* 












r-H 






































at 


os 


CO 


GO 

OS 


9 


OS 

OS 


CM 


o 


CO 


iO 
CM 








(M 


CO 


b- 


CO 


CO' 


CO 
1— 1 




t- 


t- 


fc- 


t- 


b- 


b- 


CO 


b- 


CO 


t- 


CO 


CO 












,H 



E "id .3 - 

<* ^ us « to » ^ 



13 • 

fe^^^^coiotowsa^^ 00 H ^ IT5 p N 



S^S ft (M CD COOS 

Spa ,3 ■* Hio coo to 

5 d ^ •* t" to d a 

** fl "# -* rfi .* »d "3» 



CM CO CM >0 



si 






OSO^»0»OOOSi-(000| I 

loeocor-ioosooool I 

I— I i— I r— I rH rH 

I g fe S fe g fe g fe g lij g" fe § fe g fe S fe 





^ 


t-t 


CD 


>-( 


»-. 


a> 


u 


*H 


CD 




0> 


© 


H3 


to 


CD 


nd 


o 


CD 


T3 




'V 


■73 


a 


"d 


T3 


c 


T3 


T3 


G 





P 


a 
P 


P 


a 

P 


P 


P 


G 
P 


G 
P 


P 


a 






T3 






T3 






T3 


| 


n3 


T3 


a 


T3 


-73 


g 


T3 


T3 


G 


o 


a 


G 


as 


(3 


C 


as 


13 


G 


as 


tf 


c3 * 


as 




a} 


«3 




aS 


as 








CM 






CM 






CM 




to 


OS 




CO 


OS 




CO 


OS 


1—1 


<i 


Sh 


Fh 


£_, 


Jh 


fH 


h 


u 


S_i 


s-i 




9 s 


CD 


<d 


0) 


CO 


CD 


CD 


p 


CD 




> 


> 


> 


f> 


> 


t> 


> 




> 




O 


O 


O 


O 


o 


O 


o 


6 


o 



PQ 




Plate V. Feebleminded Children showing Defective Expression. 



EXPRESSION 67 

Deafness in childhood is due in most cases to disease, 
cases of congenital deafness being really rare. In feeble- 
minded children it is not at all easy to distinguish 
between deafness and want of attention, and we shall 
discuss this more fully later (p. 129). 

Expression (see Plate V). — Defective expression is very 
common. Mobile, changeable features show a want of 
attention and an unstable temperament, and an 
apathetic, stolid look may mean that the brain is slug- 
gish, but sometimes appearances are very deceptive. 
Creasing of the forehead, twitchings of the mouth, rolling 
of the eyes are all common, but it is hard to classify or 
describe the various characteristics that go to make up 
a defective expression. It is chiefly want of control of 
the features. To the practised eye, the expression and 
control of the features and the general bearing are a 
great help in deciding whether the child is feebleminded, 
and the habit of rocking to and fro in a mechanical way 
generally indicates mental vacancy, and is found more 
often in the lower grade cases. 

One has only to watch a group of feebleminded 
children to see that most of them have some peculiarity. 

About 60 per cent, of my cases showed definite defects 
of expression. The defect is often worse when the child 
is self-conscious and doing nothing; but on the other 
hand sometimes, when the attention is concentrated on 
some action such as eating, twitchings and facial con- 
tortions may be exaggerated. It is important to note, 
however, that not all cases show this defective expres- 
sion, some of the very worst cases of feeblemindedness 
being really beautiful children both in face and form. 

Other peculiarities. — Some of these children are to a 
certain extent insensitive to pain, although this is not a 
marked characteristic. 

Disorders of menstruation are not uncommon, this 
function being in some cases absent or intermittent or in 
others very much delayed. 



68 PHYSICAL CHARACTERISTICS 

Many defectives have a strongly marked odour apart 
from the question of cleanliness. A rare skin disease, 
Adenoma Sebaceum, is sometimes seen, but is really so 
rare that it is not of great importance. 

Some have a tendency to early degeneration of the 
tissues of the body, and therefore diseases such as 
muscular wasting may occur, and there have been two 
cases of Pseudo-hypertrophic Muscular Paralysis at 
Sandlebridge, one having developed after admission. 

Epileptic fits are also not uncommon; they must not 
be confused with hysterical fits, and it is not always 
easy to distinguish between the two conditions (see 
Chapter VII). Isolated epileptic fits may occur at some 
epoch, such as dentition or puberty. 

(3) Defects Due to Want of Control. — Want of 
control often accounts for the defects of expression just 
described, but more important results are the abnor- 
malities in the general balance and carriage, which are 
very common. Many of the children are extremely 
clumsy and awkward in the playground or in the drill 
hall. This is due to poor development of co-ordination 
and control over the nerves and muscles and it usually 
persists, for, although physical drill causes great im- 
provement, feebleminded children on the average are 
below the standard in co-ordination and in games or 
drill, partly because they lack application and partly 
because they are innately less active. It is curious, when 
first one moves about amongst a group of these children, 
to find how difficult it is to avoid knocking against 
them : they seem to be clumsy and unable to get out 
of the way. 

Deficient or delayed control over the action of the 
bladder and bowels is very common, and will be con- 
sidered more fully later. However, control is usually 
learnt before the child comes to school, and, like 
delayed walking and talking, the condition is due to a 
retarded development of nerve influences. 



SUMMARY 69 

Slavering, a condition in which the saliva is con- 
stantly escaping from the mouth and running down the 
chin, is common, and is largely due to want of control 
of the lips. The condition can often be cured by teach- 
ing the child to hold suitable wedges between the lips 
for some time daily, whilst quiet and while not running 
about or playing, or to practise other exercises that give 
control over the lips. 

Summary. — Feebleminded children show the single 
physical stigmata of degeneration more often and a 
combination of two or three of these stigmata much 
more often than do ordinary children, but too much 
importance must not be attached to the presence of 
these stigmata. Of the physical stigmata of degenera- 
tion diminution in the circumference and deformities of 
the head are the most important. 

Feebleminded children tend to be smaller than 
ordinary children and to be less well developed physi- 
cally : they also tend to have poor circulations, and to 
be less resistant to exposure and disease than is the 
ordinary child. 

Most of them show a defective expression and poor 
development of control over the functions of the body. 



CHAPTER IV 

MENTAL CHARACTERISTICS 

It would be comparatively easy to write a long and 
interesting chapter by simply presenting cases illus- 
trating the mental peculiarities of the feebleminded 
children; but to describe their mental characteristics in 
an ordered and scientific manner is another matter. 
The great variability between different children only 
adds to the difficulties of our task. 

Some children are of high grade ; some, but very few, 
are peculiarly bright in some special direction, only to 
be just as deficient in others; some are more evenly 
deficient in everything; and finally some, though not 
very deficient, have no sense of right and wrong, being 
of the " Moral Defective " type. 

Under-development of the mind may be due to any 
one of three causes or to a combination of two or more 
of them : — 

(1) Defects of the ways in or the receptive paths 
to the brain. 

(2) Defects of the central, receptive, storing-up, and 

association powers. 

(3) Defects of the ways out or emissive paths. 
Taking these in order — (1) Defects of the receptive 

paths are (a) those of the hearing apparatus and its 
centre in the brain, such as congenital or early deafness 
or partial deafness causing imperfect interpretation of 
sounds heard; (b) those of the sight apparatus and its 
centre, such as blindness or imperfect sight; (c) those 

70 



CENTRAL DEFECTS 71 

of the touch and muscular sensations causing imperfect 
impressions of movements performed or of stimuli 
received on the skin or external paths of the body. 
Defects of these three paths are not very important, for, 
though they are usually defective to some degree in 
mentally deficient children and have some contributory 
effect in the causation of the peculiarities of a feeble- 
minded child, it is the central powers that are chiefly 
concerned. 

(2) Defects of these central powers are (a) deficiencies 
of the perception powers for each of the receptive paths. 
In this case stimuli are received up the paths, but do 
not make sufficient impression on the brain to be fully 
appreciated; (b) deficiencies of attention, memory, or 
one of the other mental powers; and finally (c) there 
may be deficiencies of the association, interlinking and 
co-ordinating parts of the brain : when there is want 
of power to develop association, impressions reaching the 
brain do not stimulate it to call up ideas and thoughts, 
or at any rate only do so to a slight extent. 

(3) Defects of the outgoing paths may hinder develop- 
ment of the mind, because they prevent progress and 
deprive the brain of sensations and memories that would 
otherwise be received. For instance, a child deprived 
of speech through deformity cannot get on so quickly 
as other children, nor does his brain receive any impres- 
sions of the movements of the lips or of the sound of 
the child's own voice to store up. However, defects of 
the outgoing paths are never the sole cause of feeble- 
mindedness, though they may act as contributory causes 
of the mental dullness. 

The accompanying diagram (Plate VI.) may help to 
show more clearly how impressions may reach the brain, 
to what use they are put, and how actions result from 
them, memory of these actions being transmitted to the 
brain and stored up. 

We shall now proceed to discuss certain of the 



72 



MENTAL CHARACTERISTICS 




Plate VI. Diagram to show the position in the brain of the four areas which 
have to do with the reception, the production and the storing-up of memories of 
speech, reading and writing. Note the association fibres joining up the four areas, 
each with the other three. This an an explanatory diagram only, and is not 
meant to be a scientific anatomical representation of the actual receptive areas 
in the brain. The system is far too complicated for any such representation. 



ATTENTION 73 

mental abnormalities of feebleminded children in greater 
detail. 

Attention. — Attention is of two kinds : — 

(1) Natural or spontaneous, with which the child is 

endowed. 

(2) Voluntary or established by education. 

Unless there is some power of sustained attention, 
stimuli reaching the brain are not properly used, nor 
are they stored up as experience; consequently this 
power is very important in determining mental develop- 
ment. In cases with major defects very few stimuli 
reach the brain at all, such children being idiots or 
imbeciles. 

Feebleminded children have comparatively poor 
powers of attention, especially of the voluntary kind. 
In some cases the child is, as the mother says, " bird- 
witted," its thoughts flitting so lightly from one thing 
to another that little effect is made on the brain. On 
the other hand we see children so dull and apathetic 
that it is difficult to attract their attention at all. 

Both of these types are common. It is important to 
know that the first is often of deceptively bright 
appearance, and in consequence may be thought to have 
a better chance of improving than the duller-looking 
child; but one must beware of being deceived by 
appearances. Some of the least improvable cases are of 
the first type; for instance such a child may scribble 
on a paper when asked to do so, but, noticing the fire, 
runs off to that without finishing the attempt to write, 
and is next attracted to something else almost immedi- 
ately. Calling him by name or even shouting at him 
may make not the slightest impression, but unusual 
sounds, such as the jingling of coins, often do so. 

An example of this type is — 

Case I. L. C, a medium-grade case. When testing him, it was 
at first thought that he was deaf because he neither answered 
questions nor noticed clapping of the hands or ringing of a bell. 



74 MENTAL CHARACTERISTICS 

But when a penny was dropped on the floor, the child turned 
round in a moment and looked for the coin. 

The slow child whose mental inertia makes it difficult 
to gain his attention may, nevertheless, be able to make 
some use of the impressions he does receive because he 
is not so easily distracted, and when special efforts are 
made to attract and fix his attention he may make sur- 
prising progress. 

It is curious how difficult it is to attract the notice 
of a feebleminded child from a distance. Shouting 
which would immediately attract normal children will 
produce no effect on a group of feebleminded, though a 
more unusual sound, such as that of a whistle, may 
do so. 

Sustained attention, which plays a large part in educa- 
tion, is perhaps one of the highest of mental qualities, 
and it is certainly one of those which are very poorly 
developed in the feebleminded, who have little power of 
concentration or forced attention, especially in consider- 
ing abstract ideas. They are much better in applying 
themselves to manual tasks or in learning lessons where 
attractive objects are used. 

Memory. — Closely connected with, but not wholly 
dependent on, the power of attention is memory, which 
varies very much in the feebleminded. They are often 
unable to go errands or to remember the simplest instruc- 
tions, but sometimes have curious flashes, when they 
remember events that have happened some time before. 
" Idiots savants " are also curious exceptions. It is 
quite possible to educate defective children, even idiots 
and imbeciles, up to a daily routine of duties and for 
them to carry that routine out with a certain degree of 
thoroughness; but they need constant supervision to 
keep them up to the mark, and if left to themselves 
will degenerate. 

Will Power. — The feebleminded are very easily 
swayed, and have little power of resistance to the will 



WILL-POWER 75 

of others. It is this that forms one of the chief dangers 
of letting them loose amongst the community without 
any supervision or control, for they have not the will 
to resist temptation, and in many cases come to be 
classed as criminals or drunkards. They all tend to go 
with the current, accepting every condition and making 
no effort on their own behalf ; this characteristic is more 
marked in the lower grades, but is more striking in the 
higher grades, from whom more is expected. 

A Mongol boy was one day found tying a string round the 
throat of a much bigger boy, who, though a fairly high-grade 
case, was making no effort to save himself from what were really 
serious attempts to strangle him. There is no doubt that he would 
have allowed himself to be strangled by the weaker child in so 
far as his safety and escape depended on any efforts of his own 
to defend himself. 

This acceptance of conditions and surrender to the will 
of others is a very definite, and perhaps the most 
definite, characteristic of the feebleminded, and especial 
care must be taken to guard against it. In some ways 
it is a good thing, making discipline easier and dis- 
content less frequent; but it also leads to a good deal 
of trouble. One child may make a suggestion and the 
rest follow like sheep, just as on the occasion when a 
group of boys were found working stripped to the waist, 
having followed the example of one boy who thought it 
was rather a fine idea. This same boy once set all the 
others to drink the dirty water from a ditch by the road- 
side, and they obeyed without question. 

Some children, however, may be very obstinate and 
passionate, often in pursuit of a strange whim or fancy. 

One girl, A. R., conceived a great attachment to a younger 
girl, S. A. P., and could not be consoled unless she was con- 
stantly with the other child. It became necessary to separate 
them and put them in different homes. A. R. then went to the 
length of trying to starve herself because the other girl had 
been punished. 

The feebleminded have comparatively little enterprise, 



76 MENTAL CHARACTERISTICS 

and what they have is often misdirected, while anything 
out of the ordinary puzzles them. Most have the sense 
to seek shelter from a wetting rain or avoid physical 
discomfort as far as possible, but even this cannot be 
relied on, and for this reason alone many are not fit to 
be left without supervision. An idiot is not capable of 
guarding himself against common physical dangers, and 
a feebleminded child, though never as bad as an idiot, 
often has to be watched carefully since he may not 
complain of cold or pain, bad enough to be a serious 
menace to his well-being. 

Dr. Fernald o£ Waverley, America, tells how one of the feeble- 
minded men under his care was sent to plough a field and told 
not to come back till he had finished it. The man did not return 
till a very late hour, and when he did come back it was found 
that the horse had kicked him and had fractured his arm early 
in the day. He had finished ploughing the field in spite of his 
broken arm. He had not the sense to see that his accident should 
have prevented his going on with his work, but had gone on till 
the instructions, which were all-important to his simple mind, were 
fulfilled. 

Some are less sensitive to pain than are normal people, 
but this is not a marked characteristic. It is found more 
frequently in idiots and imbeciles. Possibly the reason 
why some seem cruel or callous is that they do not 
understand what pain means ; but it is more often want 
of thought or consideration. 

Temperament. — The phlegmatic and the sanguine 
temperaments, on both of which impressions leave small 
after-effect, are often found. 

Phlegmatic children are not worried by any events but 
go on in a state of indifference, accepting all things as 
they come and seldom being disturbed. They are neither 
subject to storms of passion nor sensitive to rebuke, and 
in consequence are very difficult to teach. The sanguine 
are different. They are more lively and apparently take 
a greater interest in things, but nothing has much last- 
ing effect on them; they are impressionable, emotional, 



ASSOCIATION, IDEATION 77 

and subject to sudden outbursts which, however, soon 
pass, since generally the memory is poor and the power 
of attention bad. 

The melancholic type may dwell on a fancied grudge 
for some time, and even threaten to commit suicide, or 
they may develop melancholia and become insane as 
well as feebleminded. 

Many of the children are very sensitive to rebuke and 
much pleased with approbation; they do not like being 
passed over at an inspection, and an examination by a 
doctor can easily be made into a special treat for them, 
while a rebuke publicly administered will be enough to 
punish many of them pretty severely. 

Association and Ideation.— These powers are very 
important for education in abstract ideas and for reason- 
ing, in both of which the feebleminded are especially 
deficient, and a good test is to ask the child questions 
about some picture or object, or about school. 

In the brain there is an enormous number of associa- 
tion fibres stretching across from centre to centre and 
linking up receptive paths either with other receptive 
paths, or with outgoing paths, or with higher functions. 
Impressions received are stored up so that a stimulus 
may, by travelling along several association paths, call 
up various memories, both visual, auditory, and muscu- 
lar. Thus the word school entering the brain by the 
auditory paths calls up other auditory memories, such 
as the voice of the teacher, the visual image of the 
school-room and school-fellows, with perhaps the 
physical sense of pain conjured up by the recollection 
of some hurt received at school. In this way a stimulus 
may travel along many association paths and call up 
many memories, at the same time enabling the mind to 
reason and judge from the impression received. It is 
easy to see how absence of or diminution in the number 
of these paths will render the workings of the mind in- 
complete and often disorderly, and there is actually this 



78 MENTAL CHARACTERISTICS 

diminution in the association fibres and nerve cells in the 
brains of the feebleminded. 

High-grade cases can reason fairly well about every- 
day events, but cannot follow out a line of reasoning 
very far, and low-grade cases have much weaker powers. 

One child, a microcephalic, shown in Plate IX., who was water- 
ing some cabbages, knew quite well that he was doing it to prevent 
their drying up; but when asked whether he would water them 
if it was raining he first said yes, then after an interval said no, 
because he would not be allowed to come out in the rain. The 
idea of rain meant to him staying indoors, but his powers of 
reasoning did not carry him far enough to see that the cabbages 
would not need watering on a wet day. Other higher-grade 
children, questioned in the same way, could readily follow out the 
line of reasoning and would not have watered plants in the rain. 

In imagination, too, these children are generally lack- 
ing. They may be able to invent a world for themselves 
as the normal child does, but it is a much simpler world 
and more often they are happy in the arrangement and 
rearrangement of a few treasured possessions ; they are 
also fond of attributing human characteristics to inani- 
mate things. On the other hand, Moral Defectives are 
certainly not wanting in imagination of a mischievous 
type, and will invent most plausible tales about other 
people. 

Norsworthy in an enquiry directed to find out by 
mental tests — 

(1) Whether the mental defects were equalled by bodily defects. 

(2) Whether idiots form a separate species or not. 

(3) Whether entire mental growth is retarded, that is, there is 
lack of mental capacity all round. 

came to the conclusion — 

(1) That mental defects amongst idiots are by no means equalled 
by the bodily defects. 

(2) In general, at least so far as intelligence is concerned, 
idiots do not form a separate species, but simply occupy a position 
at the extreme of some large distribution, probably that expressed 
by the normal probable curve. 

(3) Among idiots there is not an equal lack of mental capacity 
in all directions. There is something the same lack of correlation 



MENTAL FACULTIES 79 

of traits measured in the case of idiots as there is with ordinary 
people. 

Also that idiots come nearest to the central tendency 
of children in general in the measurements of mental 
traits which are chiefly tests of maturity, and farther and 
farther away in tests of ability to deal with abstract 
data. 

The perceptive powers were found to be two-and-a- 
half times as strong and accurate as the intellectual 
powers and one-and-a-half times as strong as the 
memory. 

She sums up that the difference between normal 
children and idiots is in degree and not in kind. It is 
similar to that between very bright and mediocre 
children or between mediocre and stupid children. Her 
paper is a valuable one, and is well worth perusal. 

Other Mental Faculties. — In idiots the higher senti- 
ments are not present, and there are no feelings of 
shame, kindness, or unselfishness ; but the feebleminded 
are not so wanting in natural emotion. Defective con- 
trol often allows an unusually free play to the emotions 
so that outbreaks of violence and temper are common; 
but, though some may be unconsciously cruel and others 
may have an ineradicable impulse to irritate or injure 
animals or persons weaker than themselves, the majority 
can be trained up to habits of kindness and. gentleness. 
This is shown in some cases where the boys at Sandle- 
bridge have been given duties involving the care of 
animals, and in the way in which stronger boys protect 
and help the boy who is weak with muscular paralysis. 

Feebleminded children, especially the lower-grade 
cases, may be entirely without the sense of shyness and 
reserve that is usually noticeable in a normal child. On 
the other hand some are excessively shy, and for this 
reason are very hard to examine. It is difficult, there- 
fore, in a certain number of cases to estimate the child's 
mental capacities at the first examination, and the final 



80 MENTAL CHARACTERISTICS 

^-:~;;... ..... 

judgment has to be delayed till the child has been under 
observation for a little time. 

Since the feebleminded usually have the sense of shame 
fairly well developed, a very effectual punishment is that 
of simply putting them into disgrace. They have not 
exactly a well-developed conscience, but they can be 
made to feel that they are responsible to those in 
authority. Natural modesty is not an outstanding 
feature, and amongst the girls it is often lacking to a 
considerable degree, but it is possible by discipline and 
example to teach the children a great deal, and to make 
vast improvements in their deportment and manners, 
though there are always a certain number of intractable 
cases. 

A little harmless vanity is a very good thing, and 
should be encouraged, since it makes the child take more 
interest in his or her appearance and be more clean and 
neat. For this reason best clothes and clean linen some- 
times have a very beneficial and restraining effect, and 
it is a good thing to make it a practice that on certain 
days or at certain times the children put on their best 
clothes and their best manners. 

Home-sickness is not very common, and, unless the 
children are wilfully unsettled by their relations, they 
are seldom really discontented with institution life, nor 
do they show very strong desires to go home. Even 
with the class who are readily impressionable, feelings, 
however strong and uncontrollable they may be at the 
time, are not really deep or lasting. The departure of 
a favourite teacher may be the signal for a terrible scene 
of weeping and wailing, but it is all over very soon, and 
the new teacher duly installed in their affections. 

Moral Defectives (Plate IX., p. 108).— The official 
definition of this class has been given on page 
Another description is a person who, by reason of innate 
defect, displays at an early age vicious or criminal pro- 
pensities which are of an incorrigible or unusual nature, 



MORAL DEFECTIVES 81 

and are generally associated with some slight limitation 
of intellect. Moral defectives of the feebleminded class are 
often mentally very little below the average child. They 
are nevertheless feebleminded in that they have a definite 
and incurable mental weakness which necessitates their 
being under constant supervision ; there is a real perver- 
sion, so that an impulse, which often comes quite 
suddenly, drives the child to do things that he knows to 
be forbidden. A wrong done in a fit of furious temper 
is only loss of control, but moral defectives, though very 
liable to yield to sudden temptations to do wrong, on 
the other hand deliberately map out and execute plans 
to do harm to others, the ingenuity and cunning dis- 
played being often surprising. After having committed 
a misdeed they may seem genuinely sorry and may do 
everything to express their sorrow; but their transient 
repentance does not deter them from further outbreaks. 
Luckily discipline and judicious punishment have a cer- 
tain effect on institution or school cases, so that their 
outbreaks can be considerably diminished in number 
though they can never be eradicated. These children 
must not be confused with those who do wrong, either 
because they are ignorant or because they have no will 
of their own ; such cases simply follow suggestions made 
to them, and are usually of low grade and not really 
moral perverts. True moral defectives really form a 
very small proportion of the feebleminded, and quite a 
number of feebleminded children who have never had 
the benefit of proper discipline or care are wrongly put 
down as belonging to this class. 

Discipline and teaching can work wonders with cases 
which at first promise to be very bad. 

Moral defectives are said to form a fairly large pro- 
portion of institution cases, and to give a good deal of 
trouble to those in authority, but statistics of the various 
institutions vary considerably, and probably much 
depends on the type of case admitted and the age at 

F 



82 MENTAL CHARACTERISTICS 

which they enter and the view taken as to what consti- 
tutes moral defect. 

Many of the cases applying for admission to Sandle- 
bridge were reported to be quite unamenable to disci- 
pline or to treatment in any form, but, since they came 
at an early age, kindly and firm treatment has trans- 
formed most of them from sullen vicious children to 
fairly obedient and useful workers. These are not real 
moral defectives, but cases which have not been taught 
sufficiently what is right and what is wrong. 

Moral defectives are, many of them, of very high 
grade, and if their energies can be turned and kept to 
useful purposes they form good workers and stimulate 
the others, though, of course, they need constant super- 
vision. 

We have seen from Chapter I. that 10 per cent, of 
habitual criminals are such because they are feeble- 
minded, some of them being natural criminals and some 
being so easily led astray that they are unable to keep 
off the downward path of crime, and perhaps " Natural 
Criminals " or " Habitual Offenders " would be better 
names for these cases than Moral Defectives. The term 
Defective Delinquent has been used in America. 

Development of the Powers of Walking and Talk- 
ing. — Feebleminded children are late in learning to walk 
and talk, so that a good deal can be learned about the 
likelihood of mental development from the age at which 
these powers appear. 

A child should learn to walk and talk between the ages 
of nine to fifteen months, but of course various diseases 
may retard development of walking, and sometimes, with- 
out any known cause, children who are not feebleminded 
are very late in learning to talk. Retarded development 
of these powers does not definitely mean that there will 
be permanent mental deficiency, but it means that some 
parts of the brain, either the centres or the receptive 
or outgoing paths, are slow to take up their functions, 



DEVELOPMENT OF POWERS 83 

and that there is something delaying the evolution of the 
mental and physical faculties. 

Infirmities such as rickets, chronic tuberculous disease, 
ear disease, or wasting diseases are all capable of retard- 
ing the development of the mental and physical faculties 
and of causing mental backwardness, but the power to 
develop is present, and it is generally possible to distin- 
guish mere backwardness from feeblemindedness. 

When speech is late in developing it may be either 
because the receptive or emissive mechanisms are not 
working well, or more often because the brain is lacking 
in development, and, it may be, in power to develop. 
Intelligence and will are, of course, very important, and 
the development of speech must be anxiously awaited, 
for the longer it is delayed the greater is the likelihood 
of lifelong deficiency. The relation of the degree of 
mental and speech defects to the ages of learning to walk 
and talk are shown in the following table : — 

TABLE III 

Table showing the average ages at which five different classes of 
feebleminded children commenced to walk and talk. '* Good," 
" Medium," and " Bad " refer to the mental capacity as 
estimated by the teacher. " Defective speech " comprises 
consonantal anomalies (excluding " f " for " th "), lisping, 
and marked stammering. 

Classification of Case. 
61 cases classed as " Good " ... 
44 cases classed as " Medium " 
50 cases classed as " Bad " 
88 cases with good speech 
64 cases with defective speech... 

It is clear from this table that the greater the degree 
of mental deficiency the later the child will learn to 
walk and talk. It is possible that lateness in talking 
might have an effect on the development of the mental 
powers of a child not .feebleminded ; but to say that 
inability to talk is the cause of feeblemindedness is to 
put the cart before the horse. In any case, the effect 



Average Age, 


Average 


Walk. 


Age, Talk. 


1.5 years 


1.8 years 


1.8 years 


2.0 years 


2.2 years 


3.5 years 


1.6 years 


1.9 years 


2.2 years 


3.2 years 



84 MENTAL CHARACTERISTICS 

of such delay is slight, for children deaf from early 
infancy do not suffer seriously in mental power, in spite 
of the fact that talking is only developed late by special 
tuition. 

This table, as well as showing the definite relation 
between the delayed development of talking and walking 
and the degree of mental defect, also shows that children 
with speech defects have learnt to speak and walk later 
than those without them. This is explained chiefly by 
the fact that children with speech defects tend to be of 
low grade, and partly by the want of exercise of the 
various parts of the speech apparatus having a delaying 
effect. 

Control over the Bladder and Bowels. — Control 
over the action of the bladder and bowels is often 
deficient and delayed in the feebleminded, though to a 
lesser degree than in idiots and imbeciles. Like late- 
ness in walking and talking, such delay results from 
deficient sensation or poor development of the power of 
control over the muscles. As a symptom aiding the 
diagnosis of feeblemindedness, it is of considerable value 
in the earlier years of life, but a feebleminded child 
generally develops this control to a great extent before 
coming under examination for admission to a special 
school. It is a symptom which corresponds to a large 
extent with the degree of mental deficiency, and with a 
few exceptions the later the age at which control 
develops, the worse the prognosis as to the future mental 
state. 

Habits. — Habits such as eating coal or garbage or 

biting the fingers severely are, in children old enough 

to know better, generally evidence of a greater degree 

of mental defect. 

One of the girls at Sandlebridge had to be prevented from 
picking out and eating fish heads and other offensive matter from 
the dust-bins. She was one of the low-grade class. 

Want of cleanliness and neatness is often due to 



READING AND WRITING 85 

laziness and lack of teaching, but the lower grades are 
not readily educated up to good personal habits. 
Feebleminded children may not be able to dress them- 
selves, and are usually later in learning to do so than 
are normal children. 

Reading and Writing. — Mere inability to read cannot 
be taken as indicating mental deficiency, unless there is 
evidence that the child has had careful individual teach- 
ing and that the speech is good. It is the child's 
manner of reading or attempting to read that gives a 
valuable clue to the mental state. A nervous child 
hesitates, refuses to begin, and often breaks down; an 
impulsive or careless child hurries on, regardless of 
mistakes; a backward child is often ashamed of his in- 
ability to read, and may break down for that reason. 
Feebleminded children, if they can read at all, show 
several peculiarities. For instance, some commence 
readily, but they soon tire or the attention wanders, 
with the result that mistakes become frequent and pass 
uncorrected, and the child evidently has no idea of the 
meaning of the text. Others do not attempt to read, or 
only do so after a large amount of persuasion. 

Writing is, perhaps, a more valuable index to the 
mental state than reading, because a child often learns 
to write his name before he can read or spell words; 
moreover, besides showing certain mental characteristics, 
the act of writing calls into play the powers of muscular 
control and neatness of movement. Some of the 
children have great difficulty in deciding where to begin ; 
others write as far as the second or third letter, and 
then go on with a meaningless jumble, perhaps recover- 
ing later and adding the remainder of the word ; others 
again write one letter reversed, or else make the curious 
mistake of reversing a word and writing " god " for 
" dog." This last peculiarity is quite common, and 
sometimes persists in children who have been in the 
schools for a year or more. 



86 MENTAL CHARACTERISTICS 

Peculiarities such as (( mirror " writing and ambi- 
dexterity may occur but are exceptional. Sherlock 
states that mirror writing is a special case of ambi- 
dexterity which is commoner in idiots than in normal 
persons. He quotes Heller's and Wegener's opinions 
that the explanation of it is to be found in the natural 
tendency of movements at one side of the body to be 
accompanied by symmetrical movements at the other 
side. In mirror writing the attention is directed to what 
should be the subsidiary movement, i.e., that of the 
left hand, and the idea of this movement becomes more 
prominent and therefore controls the form the activity 
takes. 

Arithmetic and Calculation. — Feebleminded children 
are not good at calculation of any sort, and few learn 
more than simple addition. Some, with teaching, can 
do more, and a few can do simple sums in pounds, 
shillings, and pence, but the result is certainly not 
worth the time and energy spent by the teachers, for 
such knowledge is of little use to persons who can never 
be fit to have the control of money, except in very 
small sums indeed. It is therefore not worth while 
making laborious efforts to teach them the value of 
pounds, shillings, and pence when they can spend the 
time in learning useful things. Very many cannot 
even add and subtract beads or bricks with any great 
degree of accuracy, though they do much better when 
they have objects instead of figures in front of them. 

Manual Work. — It is a very good thing that these 
children have, comparatively speaking, a certain amount 
of aptitude for manual tasks. If they are to be happy 
their minds need occupation and interest, and some 
simple but congenial task is often the cause of marked 
improvement in a child who has previously been gradu- 
ally sinking every day to a lower level of intelligence. 
A weak mind cannot cope with abstract ideas as well 
as it can with things concrete and actual. 



MANUAL WORK 87 

The various occupations suitable for these children 
are described later, but the point that any occupation, 
however simple, is better than none is an important 
one. It was Cowper who said : — 

" Absence of occupation is not rest, 
A mind quite vacant is a mind distressed." 

and this certainly applies to the feeble mind as much 
as to the normal one. 

Some children have to start with the simplest tasks, 
sometimes almost absurd in their simplicity, but they 
may improve a great deal as a result of the performance 
of these, and come to be able to do useful things. 
Gardening and farm work are good for them because the 
work is out of doors, and the latter is especially suitable 
because they have usually a great liking for animals. 
Certainly some animals seem to have an instinctive 
liking for the feebleminded, and to have less fear of 
them than of normal persons. Laundry work is very 
suitable for the girls, but they should, if possible, have 
outdoor occupation as well. These children can also 
be taught to paint and draw, and so learn to judge of 
form and colour, but too much time must not be spent 
over these because it is better to pay most attention to 
teaching them useful occupations. 

Goddard has suggested a classification of " morons," 
i.e., feebleminded according to their capacity for practi- 
cal things, and it is a good one from the point of view 
of institution life. It is as follows : — 

(1) High-grade morons, who can do fairly complicated work 
with only occasional or no supervision, who can run simple 
machinery, and who can take care of animals, their only defect 
being that they are unable to plan. 

(2) Middle grade, who can do routine institution work. 

(3) Low grade, who can run errands, do light work, make beds, 
scrub, and care for rooms if there is no great complexity of 
furniture. 

He also points out that a feebleminded man of 30 



88 MENTAL CHARACTERISTICS 

years may do more work than a boy of 12 years because, 
though his mentality is no greater, yet he has had the 
18 extra years to gather experience and become accus- 
tomed to tasks. 

Many of the foregoing remarks apply more or less 
to ordinary children, and a considerable proportion of 
the feebleminded are not at first sight definitely defec- 
tive; but a little experience soon shows that to say 
that one of these children of 12 is equal to an ordinary 
child of 5 is, as remarked by the late Dr. Ashby, an 
insult to the child of 5. A child of 5 has, in spite of 
his fewer years of life, infinitely the greater power of 
making acquirements. A party of feebleminded boys 
aged from 12 to 16 need far more help in starting for 
a walk than would a set of ordinary children of 7 or 8, 
and when it comes to abstract ideas or more complex 
mental processes, the difference is more marked still. 

The high-grade moral defectives have the greatest 
mental powers, being, apart from their special failings, 
not very far below the range of ordinary intellect. 

Conclusion. — The brain of the feebleminded child is 
deficient in association paths and in receptive powers, 
so that the mind can neither make full use of stimuli 
received nor develop to the normal extent. This under- 
development, which is permanent and due to an actual 
numerical deficiency of nerve cells and nerve tissues, 
is of an irregular nature, the children differing in the 
kind and degree of the defects they present. 



V; 



CHAPTEH V 

DEFECTS OF SPEECH 

Defects of speech are common and important amongst 
the feebleminded. 

The speech apparatus consists of three mechanisms : 
(1) The lungs, which provide the blast of air to produce 
sound; (2) the larynx and vocal cords, which vibrate 
in this rush of air; and (3) the mouth, lips, tongue, 
and teeth, which form the consonants, with the palate 
and nose acting as sounding boxes. These three 
mechanisms are under the nervous control of the brain, 
and, since their muscles have to perform very exact 
and complicated movements, it can be seen how neces- 
sary is constant practice and how important is stimula- 
tion of the receptive paths for the speech centres. 

In the last chapter we have seen how impressions 
reach the brain, and reference to Plate VI. will help 
to show how speech is developed and controlled. 

There are three chief sources of the impressions that 
go to develop sensible speech, viz. : (1) From the hear- 
ing apparatus ; (2) from the seeing apparatus ; (3) from 
the sensations of the muscles, especially from those that 
have to do with speaking and writing. These sensations 
are conveyed to four specialised centres in the brain, 
each of the four centres communicating with the other 
three by interlinking fibres (see Plate VI). 

Thus impressions reaching one area stimulate others, 
and one area can call another into play. For instance, by 
these interlinking paths the area controlling the move- 

89 



90 DEFECTS OF SPEECH 

ments needed to produce speech may be stimulated 
from the hearing area, or, on the other hand, the 
movements which have produced a spoken or a written 
word may be transmitted to a sensory area and stored 
up there. 

When one wishes to remember a word or name it is 
better to store up as many memories as possible ; there- 
X^fore it is better to hear the word spoken (auditory area), 
\^to see it written (visual area), to speak it (memory of 
\,lip movement), and to write it (memory of hand move- 
ment). This shows the value of illustrations and note- 
taking in lectures and of a combination of lectures and 
reading. Some people are strong visuals, and remember 
what they have read and seen better than what they 
have heard ; others, on the contrary, receive more last- 
ing impressions through the auditory channel. VSome 
children are backward because they are " word-blind " 
or " word-deaf,' 5 that is, they have some defect in the 
areas which receive the impressions of written or spoken 
words. (Thomas.) 

Causation of Speech Defects. — We shall consider 
the causes of imperfect speech under three headings, 
viz. : — 

(A) Defects of the Ways in or Receptive Paths. 

(B) Defects of the Central Powers. 

(C) Defects of the Speech Apparatus. 

(A) Defects of the Ways in or Receptive Paths. — 
x» Defects of the actual paths conducting the impulses to 
the brain are not often the cause of speech imperfec- 
tions; the paths are very important for the develop- 
ment of speech, but even congenital complete depriva- 
tion of one sense does not prevent the child from 
learning to speak intelligently. In such cases by skilled 
tuition and by special methods the child can in time 
be taught to speak, and the brain does not ultimately 



CAUSATION 91 

seem to have suffered much from the loss of one set of 
impressions which should have come to it. 

Tactile and muscular sensations convey to the brain 
impressions of the movements required for speaking or 
writing, and are important therefore in the development 
of clear and distinct speech^so that a child with defec- 
tive sensation of the tongue has difficulty in learning the 
nature of the delicate and skilled movements required 
of those parts. 

Y Abnormalities of the brain area which receive and in- 
terpret the impulses are the cause of speech defect in a 
comparatively small number of cases only. 

(B) Central Defects.— ^The chief causes of defective 
speech in feebleminded children are defects of attention, 
will, and memory. ^ A child with a wandering attention 
misses many sounds altogether; he also hears many 
others imperfectly, because his thoughts pass on so 
rapidly that very little effect is made on the brain. 

The intelligence has naturally a great effect on the 
amount and quality of the speech, and many cases are 
due to mental inertia. The speech powers are usually 
a good indication of the mental powers, but they must 
not be taken alone in the estimation of the degree of 
defect. 

The interlinking and co-operation of the various 
centres and controlling powers is very intricate. To 
quote Wyllie : " By means of the various sense im- 
pressions a percept of each noun is formed; any hint 
will call this percept up. Audible speech does this, 
and the wonderful power of association permits the 
linking of a sound and a percept together, so that the 
word calls up the whole percept." Training and 
development of the perception centres are therefore very 
important. 

(C) Defects of the Outgoing Paths and Speech 
Apparatus. — (l)^The motor speech areas in the brain 
may have been affected by maldevelopment, or disease 



92 DEFECTS OF SPEECH 

or injury; or, apart from these conditions, the areas 
may never commence to act because there are no stimuli 
from the receptive paths. 
Xi ( 2 ) T fle powers of co-ordination play a very important 
part in the production of intelligible and connected 
speech. Not only have the three mechanisms to work 
together in perfect unison, but the parts of each 
mechanism have also to be co-ordinated. The muscles 
of the lips, tongue, throat, and palate have to perform 
the most skilled and delicately adapted movements for 
the production of a single word, and it is surprising that 
defective speech is not more common. Naturally one of 
the greatest speech defects due to want of co-ordination 
is stammering, where the three mechanisms do not act 
in unison. 

^ The babbling of infants is very important for the 
development of speech, since it necessitates the use of 
most of the consonants and vowels, and thereby gives 
constant practice to the mechanisms. It is important 
to note that one of the early signs of mental deficiency 
is absence of babbling, and a common cause of speech 
defects in feebleminded children is clumsiness of the 
movements of the mouth, tongue, and lips rather than 
any deformity. 

Shortness of the frsenum linguae or tongue-tie very 
rarely has any effect on the movements of the tongue, 
and certainly is almost negligible as a cause of speech 
imperfections, though the parents often think that it 
is the whole cause of delay in the development of 
speech. 

A defective pronunciation of a consonant might be 
an accurate representation of the imperfect impression 
received by the brain, but defective interpretation of 
impressions, though it may contribute to speech failings, 
is not of great importance in producing them; for, if 
we consider the fact that the deaf child can be taught 
consonants without the aid of hearing, it is evident that 



NATURE 93 

imperfect hearing cannot be very important in causing 
speech defects. 

Conclusions as to the causation of speech defects in 
feebleminded children. — (1) Speech defects in feeble- 
minded children are most often due to defects of the 
higher mental faculties, such as will, attention, and 
memory, and to inefficient control and education of the 
muscles moving the speech mechanism in the mouth. 

(2) They are not due to actual deformities of the 
mouth or other organs of articulation, nor to a perverted 
interpretation of sounds reaching the brain. 

Nature of Defects. — The following statistics are based 
on the examination* of eighty-four feebleminded chil- 
dren with defective speech. Many more, whose speech 
had on admission been defective, had so improved with 
tuition at the schools that they showed very few signs 
of speech troubles. This improvement shows how 
amenable many of these cases of speech defect are to 
teaching and training in pronunciation. 

In testing the speech actions, drawings, or objects can 
be used to make the child pronounce the consonant re- 
quired. This is better than asking the child to repeat 
the word after hearing it, because a child may, and 
often does, simply repeat the sound heard without under- 
standing what he is saying, thus, if he has much power 
of imitation, concealing or masking his speech defect. 
Pictures and actual things make the child speak in the 
manner natural to him. General indistinctness of speech 
is also very common, and is usually due to a slurring 
of words. 

The answers of mentally deficient children form a 
striking contrast to those of children with defective 
speech but normal intelligence, such as children with 
cleft palate. The former suffer from a paucity of ideas, 
the deficient play of the association paths making a 
great difference. 

* See Appendix III. 



94 



DEFECTS OF SPEECH 



The most striking abnormality of speech found in the 
feebleminded is lalling, or the substitution of one con- 
sonant for another. 

Wyllie in his classical work on Speech divides the 
consonants into a Physiological Alphabet as follows : — 



TABLE IV 
Consonants 



Labials 

(1st stop position) 
Labio-Dentals 

Linguo-Dentals 

Anterior 

Linguo-Palatals 
(2nd stop position) 

Linguo-Palatals 
(3rd stop position) 

Voiceless W and Voiceless L (in brackets) are rare. Former 
now only Scotland, and latter Wales. Burring (R) also bracketed. 

Vowels. 

A — eh — ah — oh — oo (like Latin). Y and W are consonants, but 
near to I and U respectively. 




Defective pronunciation of one or more consonants, 
excluding Th, is found in 32 per cent, of feebleminded 
children. T is sometimes substituted for K, and D for 
G, by children who belong to the higher grades of the 
feebleminded or by ordinary children, and it is such a 
striking defect that it is always noticed and seems much 
more common than it really is. Taking the consonants 
in the order in which they are found to be most often 
defective, we see that, as with normal children, Th is 
the consonant most often mispronounced, and next to 
that comes R. The most frequent substitute for R is 
Y (" yabbit " for " rabbit," " yaining " for " rain- 
ing "), and after Y, L, or " oo." Several children 



LALLING 95 

substituted L, R, and Y for one another almost indis- 
criminately, and this points to the conclusion that they 
had not sufficient sensation or muscular control to know 
which of the three they were going to pronounce. 

Defects of Y were almost as frequent as those of R, 
but Y could only be tested as the first letter of a word. 
It was represented by R and L, or in other cases it was 
omitted or only pronounced with difficulty. 

The fourth in frequency was S. In my cases T was 
by far the most common substitute for S and after that 
Ts. S is produced by allowing the air to pass over the 
dorsum of the tongue, while the tip is near the upper 
incisors, and should the tip become pressed against the 
incisors Ts or T is produced; hence their inter- 
changeability. 

The three main consonants of the third stop position, 
K, G, and Ng, come next. In these instances we have 
much more definite and consistent substitutions to deal 
with. K and G, if defective, are always represented by 
the corresponding consonants of the second stop posi- 
tion, while Ng is usually represented by some 
combination of N. Children with defective pronuncia- 
tion of these consonants were, in every case except one, 
very bad speakers, showing defective pronunciations of 
several other consonants as well. Defects of K and G 
are usually found together, though perhaps G is the 
more frequently mispronounced. 

Defects of Sh are common, T or some combination of 
T being the usual substitute. 

L came ninth on the list. 

The labio-dentals F and V are next. They are pro- 
duced by the lower lip and the upper teeth, and are 
intermediate between the first and second stop position. 
B is the usual substitute for V at the beginning of a 
word, and D at the end, B and D being respectively the 
labial and linguo-palatal voiced equivalents of V. 

F was usually represented by T, its linguo-palatal 



96 DEFECTS OF SPEECH 

equivalent. Defects of these consonants are the more 
easily explained when it is pointed out that they are 
produced between two great stop positions. 

The remaining consonants were seldom defective. 

The combined consonants are harder to test unless the 
child can read. Generally the defect can be traced to 
one of two forming the combination, and in this way a 
defect in the pronunciation of a consonant may occur 
only when it is in combination. L and R are very 
frequently affected in this manner. The substitution of 
Kw for Tw is explained by the much greater ease with 
which W follows on K than on T, and in the same way 
the easiest combinations to pronounce are those which 
run from the posterior positions to the anterior. The 
very common substitutes of " likle kekle " for " little 
kettle " are worthy of mention (50 per cent.), and " ss " 
in scissors in a frequent stumbling block also. These two 
peculiarities, though by no means confined to feeble- 
minded children, are not so often found in children of 
ordinary intelligence at the same age. 

Feebleminded children often drop the last letters 
through slovenliness or want of attention or through too 
rapid speaking. This fault, like the faulty pronuncia- 
tion of double consonants, is more common in feeble- 
minded than in ordinary children. 

A few careful lessons in the adjustment of the tongue 
and lips often produce a considerable improvement in 
the better class of the feebleminded, but such improve- 
ment is too often only temporary. Patient and sustained 
practice is needed to produce any lasting effect, and 
it is essentially in will-power for such practice that the 
feebleminded are lacking. The consonants needing the 
conjoined action of the dorsum, edges, and tip of the 
tongue for their production are most frequently defec- 
tive. R, Y, Th, S, and Sh are all examples of this 
class, and these are shown by the tables to be the most 
commonly defective. 



STAMMERING 97 

The substitution occurring in the second stop position 
is often almost indiscriminate, a fact which points to a 
want of co-ordination and control of the united action 
of the tongue muscles. From R it is a progressive 
transition to the indefinite " oo," then to Y, and finally 
to the burring or uvular R. The " oo " sound may 
become W if the lips are called into play. The labials 
are produced by simple movements, which can be seen 
and imitated, and consequently they are not often 
affected. 

The faculty of imitation also helps the development 
of speech very much. 

A lazy or clumsy child is only too likely to lack the 
precision to speak properly, and, just as some clumsy 
children improve much more with drill than do others, 
so some children improve in speaking much more than 
others. But the teaching has a great deal to do with 
it, and the methods employed must be adapted to the 
different children. Dr. Ireland has suggested that 
speech defects may be like those troubles that affect 
certain groups of limb muscles in the feebleminded. 

In many instances lalling closely resembles the babyish 
speech of a young child ; still it is a much more definite 
affection, and ordinary children obtain control of speech 
at an age when many of the feebleminded have not tried 
to say a word. 

Stammering is a spasmodic arrest of utterance, and 
Stuttering is a spasmodic repetition of initial syllables 
of words (Guthrie). Stammering and stuttering only 
occurred in 2.4 per cent, of the feebleminded children 
examined. Stammering is usually produced by spasm 
or by inco-ordination of the three mechanisms. For 
example the respiratory mechanism attempts to expel 
the air, but the vocal cords remain firmly closed, while 
all the time the oral (mouth) mechanism keeps repeating 
the movements needed for the pronunciation of the first 
consonant; an overflow of energy may take place, and 

G 



98 DEFECTS OF SPEECH 

take the form of facial contortions or stamping, and 
finally when the air is released it is often expended in 
producing the voice for one word only. Stuttering is 
often due to imperfect respiratory control, and is often 
amenable to treatment by respiratory exercises. 

To sum up. — (1) Lalling or substitution of consonants 
is a common defect in feebleminded children, but it is 
often combined with general indistinctness of speech. 

(2) Lalling is an important symptom of feebleminded- 
ness, though it may occur in children of average 
intelligence. 

(3) It is generally due to inefficiency of the muscles 
of the oral mechanism, and can be remedied if the child 
has the intelligence to learn and the will to practise. 
Amongst the feebleminded want of attention and want 
of intelligence contribute largely to the production of 
lalling, but deficient development of muscular control 
is the most important cause, just as it is the cause of 
clumsiness of the limbs. 





3. 



4. 



Plate VII. Cretinism. Figures .1 and 2 show 
1910. Height 2ft. IHins., weight 351bs. 4 
Fig. 3 shows the same child 
3ft. lin., weight 301bs. 



E. S. before treatment 
circumference of abdom 



in Apr 
o/.s. , 
in August, 1010, after four mouths' treatment. Height 
Mozs., abdomen 19iins. The mental condition is very much 
improved. Fig. 4 shows a cretin, who has improved with treatment, 



but remains 



feebleminded. 



CHAPTER VI 

SPECIAL TYPES 

A minority (less than 10 per cent., see Chap. III.) of 
feebleminded children belong to one or other of the 
Special Types, which all present certain peculiarities 
and characteristics, and are more common amongst the 
lower grades of mental defect, idiocy and imbecility. 

The following types will be described : — (1) The 
Cretin; (2) the Mongol; (3) the Microcephalic; (4) 
Acquired forms, which are (a) the Paralytic or Cerebral 
Diplegic and Hemiplegic, (b) the Inflammatory 
(Meningitic and Encephalitic), (c) the Hydrocephalic. 

(1) Cretinism. — Cretinism or congenital myxcedema 
is a condition due to the absence of the thyroid gland. 
This gland produces a powerful internal secretion, the 
absence of which gives rise to certain definite symptoms. 

It is more common in hilly districts, such as Derby- 
shire, where there are isolated villages, but a certain 
number of cases arise in all parts of the country. 

Characteristics (see Plate VII.). — The cretin is much 
coarser in every way than the normal child. This 
coarseness is due to the collection of semi-fluid material 
just underneath the skin, which gives the child a bloated 
appearance. The main characteristics are thick coarse 
features, rough dry skin, a harsh voice, a large clumsy 
tongue, dry, poorly-nourished hair, swellings resembling 
pads over each collar bone, a protuberant abdomen with 
a low umbilicus, short square hands, and lastly, what 
is often the most striking feature, great stunting of the 

99 



100 SPECIAL TYPES 

body and limbs. As the thyroid gland is wanting, the 
trachea can usually be felt very clearly. There is usually 
marked constipation. Mentally a cretin is very listless 
and heavy, having as a rule greatly diminished power 
of independent thought or action. The child is in a 
condition of hebetude or apathy, and if untreated be- 
comes a hopeless imbecile, docile enough but quite unfit 
to form a useful member of the community. Slighter 
forms of cretinism are met with, and it is quite possible 
for illness during infancy or childhood so to affect the 
thyroid gland as to derange its function and cause 
mental dullness with stunting. But true feebleminded- 
ness is not likely to be caused in this way. 

Prognosis. — The future of the cretin is not always 
a bright one, even though efficient treatment is com- 
menced early. Most of them improve wonderfully, and 
are transformed from gross, ugly creatures into more or 
less intelligent looking children; but though they show 
such a marked reaction to treatment, the average case 
never gets beyond a certain point, and is feebleminded 
for the rest of his days. 

Of course these children are not likely to show the 
stigmata of degeneration, or to have family histories 
of hereditary mental trouble. 

Treatment. — The effect of treatment can be seen in 
Plate VII., and consists of giving doses of extract of 
sheep's thyroid to take the place of the child's missing 
thyroid secretion. It must necessarily be continued for 
life. The remedy can be given as tablets, beginning 
with small doses of 1 grain and increasing to 2J, 5, or 
more grains three times daily, or the liquid extract may 
be used. 

For a fuller account of the condition the reader is 
referred to text-books of medicine or children's diseases. 

(2) Mongolian Imbecility. — Dr. Langdon Down first 
described the type of mentally deficient child known as 
Mongolian (Plate VIII.). All these children bear a 



MONGOLIAN TYPE 101 

curious featural resemblance to one another, so marked 
that a Mongol is easily recognised at a distance by a 
skilled observer. The features are like those of the 
Mongolian race, the main characteristics being the 
obliquity of the eyes and eyebrows and the depressed 
bridge of the nose. Anyone dealing with large numbers 
of patients at a Children's Hospital will see quite a 
number of Mongols, but since many of them die in 
infancy, they are not common amongst older children. 

Causation. — Mongolism, though a very definite type, 
is probably a failure of development like the other forms 
of primary feeblemindedness, examination of the brain 
showing irregularity and incompleteness of formation. 

The condition seems to be in many cases the result 
of an exhaustion of the reproductive powers of one or 
other of the parents. A few cases are met with where 
the parents are young and strong (see footnote), but 
by far the majority of the cases are the last of a large 
family, the parents having reached the age of 40 or 
thereabouts. 

The following is the history of a ease under my care : 

F. C, set. 8 months. Family history negative for neuropathic 
taint and for tuberculosis. Father youngest of his family, mother 
eldest of hers. Mother had bad health during this pregnancy and 
was very depressed. There have been twelve pregnancies : — (1) 
Girl, well aged, 23; (2) boy, well aged, 21; (8) boy, well aged, 
19; (4) boy died at 6 years old; (5) boy, well aged, 15; (6) boy, 
well aged, 13; (7) girl, well aged, 11; (8) boy, well aged, 9; 
(9) girl, well aged, 7 ; (10) boy, well aged, 5 ; (11) boy, well aged, 
3; (12) premature and still-born; (13) F.C., a Mongol. 

The list of family histories and ages of parents col- 
lected from various sources and given below,* shows 

*Of 63 Mongols that have come under my own observation in 
Manchester, 44 were the last children of their respective families 
and 15 the last but one. Four were the first children; all the 
four parents of two of these four were over forty years of age, 
and of the four parents of the other two, three were twenty-eight 
and one twenty-six. 

In 132 families, each containing a Mongol, there were in all 



102 SPECIAL TYPES 

how frequently the Mongol is the last child of a large 
family, and how often the parents are of advanced age ; 
it also points very strongly to the fact that the 
Mongolian type of mental deficiency is due to an exhaus- 
tion of the reproductive powers of one or other or both 
of the parents. There is no evidence to show either 
that syphilis in the parents, or that dissimilarity in the 
age of the parents, have any effect in causing this form 
of mental deficiency. 

Pathology. — As Dr. Shuttleworth has suggested, the 
various deformities point to a generally unfinished state, 
the poorly developed ears, the lax ligaments and 
hypotonia of the muscles, the not uncommonly incom- 
plete condition of the heart and brain all indicating a 
state of unfinished development. The brains of Mongols 
seem to differ considerably, the convolutions being 
usually primitive and much more simple than is normal ; 
some show gross signs of arrested development or of 
smallness or simplicity of certain parts, others show 
marked changes in the cerebral cortex, while others 

827 children, giving an average of six to each family. Of these 
827 children only one was feebleminded apart from the Mongols. 
It is very rare indeed to find another mentally defective child in 
a family that contains a Mongol, the case quoted above being the 
only instance known to me. It is interesting to note that one 
instance of Mongol twins has been reported and several of twins, 
one of which was a Mongol. (Shuttleworth, quoted by Thomson.) 

Of 336 cases collected from medical literature, 198 were the last 
children in their respective families, and 44 the first. Of 132 
Mongols 14 were the first born, 14 second, 39 third, fourth, and 
fifth, 34 sixth, seventh, and eighth, and 31 ninth to fourteenth. 
The Earlswood tables show that 22 per cent, belong to the first 
half and 78 per cent, to the latter half of the families. 

Of 27 mothers and 19 fathers of Mongols 77 per cent, and 68 
per cent, respectively were between the ages of thirty-seven and 
forty-four, and some were over the age of forty-four. 

In all the cases except one, where there was a reliable family 
history, it was negative for any neuropathic taint, and as stated 
above in one case only was there another mentally deficient child 
in a family containing a Mongol — facts which make it improbable 
that this form of mental deficiency is due to an inherited taint. 




Plate VIII. Feebleminded Children of the Mongolian Type. 



MONGOLIAN TYPE 103 

again show few definite abnormalities.* Probably the 
deformities tend to be greater or less with the greater 
or less degree of Mongolism. 

Deformity of the skull exists because the brain is 
small and does not develop normally, and just as the 
bones of the skull of the microcephalic close early 
because the brain is so small, so premature closure of 
the bones of the base of the cranium, if present, is due 
to imperfect development of the brain and not to 
primary deformity. 

In many Mongols the thyroid gland is smaller than 
normal, but the pituitary body seems to be unchanged. 
The majority of cases do not show any changes of the 
ductless glands, and there is nothing pathological to 
indicate that Mongolism is anything but a failure of 
development. 

Characteristics — Physical and Mental (see Plate 
VIII.). — The physical characteristics are numerous. 
There is the peculiar obliquity of the orbits, already 
described, and this, combined with the depressed bridge 
of the nose, a deformity said to be due to premature 
joining of the bones at the base of the skull, gives to 
the face of the Mongol its characteristic appearance. 
Protrusion and sucking of the tongue is very noticeable 
in some Mongols, especially in infants. Epicanthic folds 
are often present. The heads are small and round, being 
deficient behind, so that the skull ascends very steeply 
from the back of the neck. A typical Mongol seems to 
have an under-development of the bones in the region of 
the nose and upper jaw, so that the face has a pinched- 

*I have examined the brains of four Mongols, and found that 
three of them showed simplicity of the convolutions and a rounded 
appearance. The fourth (that of a Mongol of marked degree, who 
died in infancy) showed gross abnormalities and primitive type of 
the convolutions of the cerebrum and smallness and underdevelop- 
ment of the cerebellum. 

One of these cases died of general tuberculosis and had tuber- 
culous meningitis. 



104 SPECIAL TYPES 

up appearance and the lower jaw appears to be too big 
and to protrude laterally. The ears are generally small 
and crumpled, the upper part of the pinna overhanging 
and protruding. The hair is often thin and sparse but 
may be normal. The cheeks of those who survive 
infancy are usually rosy and plump, the outline of the 
lower jaw being rounded ; this gives the child a look of 
robust health. On the other hand many Mongol infants 
are pale, thin, and wasted and do not survive long, 
being classed as wasting babies and never being recog- 
nised as Mongols. In older cases the skin is coarse, and 
a growth of downy hair is often present on various parts 
of the body. The hands are square with short fingers, 
the little finger being incurved, and the feet are also 
square ; the joints and muscles are sometimes very loose, 
permitting of unusual attitudes; furrows are very 
numerous on the palms of the hands and on the tongue, 
those on the tongue being in later life often extraordin- 
narily well marked; the palate may be high or 
V-shaped; the eyes are often defective, and many 
Mongols are brought at first to an Eye Hospital, since, 
in addition to the obliquity of the palpebral fissure, the 
tendency to eye-rolling is sometimes very noticeable; 
squint or nystagmus may occur, too, and in many cases 
(62 per cent.) congenital cataract is present. (Ormond.) 
Congenital heart deformity is quite common in 
Mongols, and they should always be examined for bruits 
or enlargement of the cardiac dulness. Dr. Still states 
that congenital heart disease is found in 5 per cent, of 
Mongols. Mongols show a lowered resistance to cold, 
many of them having cold extremities, which become 
blue on exposure, a phenomenon that may be quite 
independent of heart trouble. This general lowered 
resistance renders Mongols liable to infection, to tuber- 
culosis, to pneumonia, and to bad effects from opera- 
tions. They are also liable to sudden death, as in a case 
under my ,care in hospital, who suddenly developed dark- 



MONGOLIAN TYPE 105 

red patches on the trunk and limbs, a high temperature, 
and died in a few minutes. 

Mongols also tend to be much below the average in 
height and weight. A Mongol of 8 or 9 years often 
resembles a normal child of four or five in appearance. 
This characteristic is also noticeable in infant Mongols, 
especially in those who do badly, for they remain much 
under the average weight and length. The small weight 
might be due to wasting, but the failure to grow in 
length is a developmental defect. One of my cases, aged 
1 year and 2 months, resembled in length, weight, and 
appearance a poorly nourished baby of 3 months. 

Mongols are very difficult to teach. They have very 
good powers of mimicry, and will imitate animals or 
sometimes persons very closely, being in this way often 
very amusing to the other children. They are usually 
fairly happy and contented, but many of them are of 
low grade, and not very many are found suitable for 
treatment as feebleminded; they are usually of the 
imbecile grade. Another curious point is that they are 
very fond of music, more so than are other children. 

Prognosis. — The prognosis is not good. Quite a large 
number die in infancy, being classed as wasting babies, 
and thus escaping recognition as Mongols. Those who 
live to a later age and survive the malnutrition stage 
show a weakened resisting power to disease, and there- 
fore succumb readily. Pearce and Rankine, judging 
from 50 cases, give the average age at death as 
141 years. 

Tuberculosis, occurring most commonly in its pul- 
monary or miliary forms, is responsible for the death 
of a very large proportion of cases. Broncho-pneumonia 
also may easily be fatal. Probably the largest propor- 
tion of Mongols die in infancy or very early childhood 
of malnutrition and atrophy. If congenital heart 
trouble is present, the child has a still weaker hold on 
life. 



106 SPECIAL TYPES 

Apart from physical infirmities, the outlook as regards 
the future mental state is not good. The mental con- 
dition improves very little, and, although these children 
are often happy and look bright, their mental level is 
usually that of an imbecile and may be lower still. 
There are slighter cases with very little defect, but the 
majority are low grade. 

Treatment. — Occasionally a combination of Mongolism 
and Cretinism occurs, and in such cases treatment with 
thyroid extract improves the child mentally and physi- 
cally to a certain point. There are no special measures 
for improving Mongols, but every effort should be made 
to give them some occupation that interests them even 
if it is of the simplest kind. The eyes should always 
be examined and defective vision corrected by spectacles. 

(3) Microcephaly. — In this form of mental deficiency 
the brain is very small, so that the sutures and fontan- 
elles of the skull close early and the circumference of the 
skull is a good deal smaller than it should be. Small- 
ness of the head, within certain limits, does not neces- 
sarily mean less intellect, many children with small 
heads being very clever; but in microcephaly the head 
is extraordinarily small. 

The normal head should be at least well over 19 

inches in circumference in a school child. The following 

are actual measurements from cases of microcephaly at 

various ages : — 

At 3 months 12 inches; at 3 years 15 inches; at 9 years 
15f inches. 

Causation. — Unlike Mongolism, Microcephaly often 
affects several children in one family, sometimes affect- 
ing all the children. In some instances one or other of 
the parents has had a very small head; in others there 
is a definite history of descent from a feebleminded 
individual. 

Murdoch records a case in which a family of five 
microcephalic children was the progeny of two of the 



MICROCEPHALY 107 

descendants of a feebleminded woman. This woman 
had had four feebleminded girls, all of whom had had 
feebleminded children. The descendants of the original 
feebleminded woman included more than 100 feeble- 
minded persons, amongst whom was the family of five 
microcephalics. The father of these was feebleminded 
but not microcephalic. 

The following are notes on the history of a family 
containing microcephalics, some of whom have been 
under my observation in Manchester : — 

Father and mother of good mental powers and aged 35 and 34 
respectively : both temperate : children 8 in number. (1) Boy, 
alive, aged 12, good mental powers; in Std. V. (2) Boy, alive, 
aged 10, Microcephalic in Royal Albert Asylum, Lancaster. (3) 
Girl, alive, aged 8, fair mental powers; in Std. II. (4) Boy, 
alive, aged 6, Microcephalic. (5) Boy, stillborn, Microcephalic. 
(6) Boy, died, aged 3 months, Microcephalic. (7) Girl, died, 
aged 8 months, Microcephalic. (8) Girl, alive, aged 6 months, 
Microcephalic. After careful enquiry it was found that there was 
no history of Insanity, Fits, Mental Deficiency, Tuberculosis, or 
Intemperance either in the parents and their brothers and sisters 
or in the grandparents. 

It is noticeable that out of the eight children born to 
these parents six were microcephalics. 

Thirty-three per cent, of my cases showed a family 
history of mental trouble. 

Pathology. — The brain is much smaller than the 
average, and shows simplicity of convolutions; beyond 
this there is nothing especially characteristic of the 
microcephalic brains, though some of them show major 
defects, such as extreme smallness of the cerebellum. 
The skull closes early because the brain is so small; 
consequently the child usually has a narrow receding 
forehead and a more or less pointed skull cap. 

The face, body, and limbs are usually well developed, 
and, except that, in the more extreme cases there is 
often spasticity and stiffness of the limbs, a micro- 
cephalic child shows little physical deformity other than 
that of the head. 



108 SPECIAL TYPES 

Characteristics (see Plate IX., Figs 1 and 2). — The 
appearance of these children is very characteristic, the 
skull being so small and so obviously out of proportion 
to the face that there is little difficulty in recognising 
the condition. In consequence of the small size of the 
skull there is usually a history of rapid termination of 
labour at the birth of the child. Some of the children 
suffer from convulsions, others show the spasticity or 
stiffness of the limbs referred to above, this stiffness 
being most common in the lower limbs. Constipation 
is often a troublesome feature. Both the spasticity and 
the constipation are probably due to defective nervous 
control from under-development of the upper motor 
neurons. 

Though often amiable and bright, microcephalics are 
subject to violent and passionate outbreaks, during 
which they may do damage. Some cases are very rest- 
less and quick in their movements, showing a curious 
resemblance to a bird. Like other mentally defective 
children they are late in learning to walk and talk, and 
many of them never learn to talk at all, but do no more 
than make inarticulate sounds of pleasure or pain. 

The cases which come under the classification of 
feebleminded are the best of the microcephalics. For 
this reason the characteristics seen in the more marked 
cases, such as stiffness of the limbs and inability to 
talk, are not present in cases seen in special schools 
or colonies. 

Prognosis. — The prognosis as regards life is good, but 
the microcephalic feebleminded are usually of low grade, 
and, though often imitative, are difficult to teach. 

Treatment. — Treatment directed to curing the condi- 
tion is of no avail. At one time the operation of 
craniectomy or of opening and raising the skull bones 
with the idea of giving the brain room to develop was 
tried in a number of cases but quite unsuccessfully, and 
to argue that the brain does not develop because the 



1. 





3. 



4. 



Plate IX. Microcephalic (Figs. 1 and 2), Hydrocephalic (Fig. 8) and 
Morally Defective (Fig. 4) Types. 



ACQUIRED FORMS 109 

skull is too small is to put the cart before the horse. 
What really happens is that the brain is abnormally 
small from the first, so that the skull does not attain 
the right dimensions. Of course, by treatment, train- 
ing, and teaching a fair amount can be done to develop 
the mental powers, but there is no operation or surgical 
measure which can affect in any way a brain which is 
small because of the failure of the formative processes 
that go on while the child is still in utero. 

(4) Acquired Forms. — Acquired forms are due to 
causes acting during intra-uterine life or early child- 
hood on a brain that, apart from these causes, would 
have developed normally. Nearly all these cases can be 
classed as being due to inflammatory lesions. 

The several acquired forms of feeblemindedness are 

(a) the Paralytic (Cerebral Diplegic and Hemiplegic), 

(b) the Inflammatory, and (c) the Hydrocephalic. 

(a) Paralytic* (Cerebral Diplegia or Hemiplegia). — 
In Diplegic cases all the limbs or both legs may be 
affected : in Hemiplegic cases only one side of the body 
is deformed. 

In Paralytic cases there has been some destruction of 

part of the upper motor neurons or of the conducting 

paths of the brain during intra-uterine life or at birth, 

either by haemorrhage or by other conditions such as 

injury or inflammation. In some there is a severe lesion 

during intra-uterine life, so severe that the child would 

not have survived if it had been living a separate 

existence at the time the lesion occurred : in others the 

destructive process is not so severe, and may occur at 

birth without causing the death of the child; in others 

again there is no definite evidence of a destructive lesion 

but only poor development of the nerve cells of the 

upper motor neurons (Shaw). Whatever the nature of 

* Dr Fernald holds that injustice is often done to paralytic 
feebleminded, who, being much hampered by physical defect, 
may be graded with children of a lower mental class than them- 
selves and miss the training which is due to them. 



110 SPECIAL TYPES 

the pathological lesion the effect is much the same, 
because the nerve cells or the nerve processes of the 
upper motor neurons are rendered defective to a greater 
or lesser extent, and a stiff or spastic paralysis with 
accompanying mental deficiency is the result. 
f^d Causation. — There is often a history of difficult birth 
in these cases. Obstruction to the birth of the child 
causes prolongation of labour, which may give rise to 
effusion of blood on to the brain, since the blood vessels 
of the child's brain are unable to resist the strain of 
continuous congestion and pressure. This shows how 
valuable is the use of instruments when labour is un- 
duly prolonged. Again, there may be a history of 
injury to mother and child during pregnancy or of 
severe illness of the mother. 

Characteristics (see Plate X.). — A typical case of 
Diplegia of moderate severity shows stiffness and rigidity 
of the limbs, the legs being most commonly affected; 
both sides are equally bad and the reflexes are increased. 
The condition is a typical spastic paralysis of greater 
or lesser degree. This stiffness leads to considerable 
awkwardness and limitation of movement, and in some 
of the worst cases of cerebral diplegia there is even 
spasm of the back muscles, causing arching of the spine. 
Speech may be affected, and both walking and speech 
are late in developing. 

Mentally, cerebral diplegics may be fairly good com- 
pared to other feebleminded children, and though they 
are often very excitable and emotional, as in Case I. 
(J. D., p. Ill), they may be comparatively intelligent, 
teachable, and capable of mental development. The 
brain has been fully endowed, but its development has 
been arrested. However, they are usually at least 
feebleminded, and are dependent on other persons on 
account of both their mental and physical infirmities. 

Cases of microcephaly may show a similar stiffness, 
but the smallness of the head serves to distinguish 




fcffi 



8. 



Plate X. Feebleminded Children of the Paralytic (Hemiplegic) 
Type. Fig. 1 shows the small size of the affected limb in four cases of 
Hemiplegia. Figs. 2 and 3 show athetoid, involuntary movements in 
the affected arm of the case on the left of the group in Fig. 1. 



PARALYTIC FORMS 111 

the two conditions; moreover the microcephalic with 
spasticity exhibits much poorer mental power than a 
feebleminded cerebral diplegic. 

Paralytic cases show a great tendency to slaver, and 
there may be a constant stream running down the child's 
chin and wetting his clothing. 

In Hemiplegia only one side of the body is affected. 
The arm and leg are usually paralysed together, but the 
face may also show evidences of one-sided paralysis. 
The affected limbs are stiff and much weaker than those 
of the other side, and are generally smaller also, as 
they have not grown at the same rate. This charac- 
teristic can be seen in Plate X., which also shows the 
curious involuntary twistings and contortions of the 
affected parts, known as athetosis. 

In both diplegia and hemiplegia there is a tendency 
to the development of contractures of the muscles on 
the flexor surface of the limbs, which may be fixed in 
a bent position in consequence. 

Deformities of the head corresponding to the site of 
the lesion occur. Thus a child with hemiplegia of the 
right arm and leg may have smallness of the left side 
of the head.* 

Treatment. — There is no specific treatment either 
operative or medicinal, for this condition. Some cases 
improve a little under potassium iodide and mercury. 

Regular massage and drill aiming at educating the 
nerve paths to the muscles and the nerve centres from 
which impulses arise, is of considerable value, and, 
since these cases may possess patience and will-power 
much in advance of the ordinary feebleminded child, 
they may learn to do work needing fine adjustment and 
skilled movement. 

Case I. J. D., aet. 4 years. Cerebral Diplegia. Cannot walk or 
talk, though attempts a few words; always slobbering; obstinate 

* The left half of the brain controls the right side of the 
bod}' and vice versa. 



112 SPECIAL TYPES 

constipation; head 20 in. in circumference; difficult birth, pro- 
longed and instrumental; child had convulsions at birth; legs 
spastic and weak; reflexes increased. Under regular massage and 
exercises designed to educate muscular control the child is im- 
proving and can now walk across the room, but tends to get 
excited and hurry, when he falls. His mental condition is im- 
proving with training, but he will always be dependent on others. 
Case II. H. W., ast. 7 years. Hemiplegia left side. Can walk 
unsteadily, the left leg dragging at times and the left arm being 
bent at the elbow and not under control; saliva always running 
from his mouth; head 18| in. in circumference; paralysis present 
from birth; left arm and leg weaker and thinner than right; 
left hand contracted and fingers bent inwards; mentally very 
vacant and poor. 

(b) Inflammatory (Meningitic and Encephalitic). — 
Inflammatory conditions such as meningitis and 
encephalitis may cause either (1) retarded mental 
development by sense deprivation, which gives rise to 
deafness or blindness or a combination of the two ; or 
(2) mental deficiency by the effects produced on the 
brain by the inflammation. In the sense-deprivation 
cases there is not real mental deficiency, and these cases 
can develop mentally as soon as the receptive paths to 
the brain centres are opened. Proof of this can be 
found at the schools for the deaf and blind and in the 
example of Miss Helen Keller, who, though deaf and 
blind from very early infancy, is now the author of 
two well-known books and whose intelligence is of a 
high order. 

But when the inflammatory changes actually affect the 
brain and cause sclerosis or scar formation, there may 
be real and permanent mental deficiency. These in- 
flammations may occur (1) during intra-uterine life, as 
is shown by pathological evidence; (2) during infancy 
and childhood either from postbasic meningitis due to 
the diplococcus intracellularis, or to pneumococcal 
meningitis, or from acute encephalitis causing destruc- 
tion of the grey matter of the brain ; and (3) may follow 
some of the acute infectious fevers, such as scarlet fever 
or measles. Meningitis is not a common cause of mental 



HYDROCEPHALIC FORM 113 

deficiency, though some alienists hold that intra-uterine 
meningitis is responsible for a good many cases. 

(c) Hydrocephalic. — This is the condition commonly 
known as " water on the brain." The brain is a hollow 
organ, the cavities in each hemisphere being known as 
ventricles. The fluid in hydrocephalus may be (1) in 
these ventricles, in which case it distends them and 
compresses the brain; and rarely either (2) between the 
skull and the brain, in which case it presses on the brain ; 
or (3) both inside the ventricles and between the brain 
and skull. 

The pressure of this fluid on the brain may ultimately 
cause feebleness of intellect if the child survives, but 
hydrocephalic cases are not at all common in the feeble- 
minded; they are seen more often as hospital patients. 
Congenital hydrocephalus does occur, but the child is 
not necessarily weak-minded. There is little difficulty 
in recognising hydrocephalus (see Plate IX.), for the 
head is very large, being often 25-27 inches in circum- 
ference, and the skin may be so tightly stretched in a 
marked case that the upper parts of the whites of the 
eyes are visible, while the pupil is hidden by the lower 
eyelid. A word of warning should be given against mis- 
taking the large bossy square head of rickets for hydro- 
cephalus. The congenital condition known as spina 
bifida may be followed by hydrocephalus. If the child 
survives, it may be paralysed and mentally defective, 
but these cases again fall more naturally into the pro- 
vince of hospital treatment. 

Treatment. — The medical treatment of these forms of 
feeblemindedness, when there is real brain mischief, is 
of little value. The children remain permanently of 
feeble intellect, though they can be taught a fair 
amount. Potassium iodide is the only drug that may 
be beneficial, but the inflammatory mischief is usually of 
old standing and is not likely to react to medicine. 

In the cases of sense-deprivation there should be great 

H 



114 SPECIAL TYPES 

improvement with medical treatment and proper 
methods of teaching, the condition being merely back- 
wardness due to want of stimulus. 

In other cases where there is mental deficiency as well 
as deafness or blindness, the child may appear much 
worse than he really is because he is both backward 
and feebleminded; it follows that some cases improve 
beyond expectation. 

Oxycephaly or steeple skull. Ateleiosis, or con- 
tinued youth, a type to which Tom Thumb belonged, 
and Progeria, or premature old age, are too rare to 
merit a special description here. 

Amongst my hospital cases there are records of one 
case of Juvenile General Paralysis, but this is a pro- 
gressive disease and does not concern us here. 

Moral Defectives are described in Chapter IV., 
(p. 80), because their characteristics are mental rather 
than physical. 

Finally, let it once more be emphasised that only a 
small minority of feebleminded children belong to the 
special types. 



CHAPTER VII 

DIAGNOSIS 

In making a diagnosis of the mental condition of the 
child brought up for admission to a special school or 
institution for the feebleminded, the medical officer has 
first to decide whether the child is below the normal 
mental level, and, if this is so, he has to place the child 
in one of three classes : (1) Dull or backward, (2) 
Feebleminded, (3) Imbecile or Idiot. Certain " border- 
line " cases have to be admitted and watched before a 
definite diagnosis can be made. 

Imbecility and Idiocy have already been defined. The 
term Backward Children includes two main classes : — 

(1) Intelligent children, who for some reason are not 
up to the average standard of knowledge; usually 
either because they have come to school late or because 
they have some physical defect, such as deafness or 
short-sight, which renders them unable to reap the same 
benefits from teaching as do the other children. These 
cases are in low standards because they cannot have 
individual and special teaching. 

(2) Dull children, in whom the mental dulness is due 
to physical causes such as disease, epilepsy, or bad 
environment, the effect of which is to impair the activity 
of the brain. These children are in low standards 
because they need treatment directed to improving the 
nutrition and tone of the body and brain or the removal 
of dulling factors such as epilepsy. 

Of the children admitted those dull or backward may 
115 



116 DIAGNOSIS 

improve with individual and special treatment, and can 
then be discharged; and those of the lowest grade may 
be found to be too bad for treatment and sent to other 
places for care. 

In this chapter we shall discuss the points which help 
us to choose cases suitable for treatment and training 
as feebleminded. 

It is very important to take exact records of each 
case at the time of examination, and to continue these 
while the child is under observation. To be of any 
value, such records must be full and definite. Histories 
or notes which leave any doubt are practically useless, 
and only that information which comes from a reliable 
source should be accepted. For instance, many mothers 
will give a history of convulsions in several of their 
children, but a more careful questioning will show that 
the fits have only been terminal events in some other 
illness, or that they have not been real; others describe 
as " inward convulsions " what were probably griping 
pains and not fits at all. In the same way family 
histories of consumption or alcoholism must be verified 
before they can be used for statistical purposes. These 
warnings are not meant to deter anyone from taking 
records. On the contrary, reliable records are urgently 
needed, and are most valuable for scientific research 
and progress in this subject; but it cannot be too 
emphatically pointed out that the utmost care must be 
exercised. 

The following apparatus is necessary : — (a) A measure 
marked in inches and centimetres and made of tape, not 
of wire or steel; (b) a machine for measuring heights 
and weights; (c) case sheets and boxes for filing; (d) 
a stethoscope; (e) a simple tongue depressor, which 
should stand in a bowl of antiseptic lotion, or a few 
firm strips of wood, a fresh strip being used for each 
child; (/) a good firm table on which are a number of 
(g) coloured wools or papers, the colours represented 



APPARATUS 117 

being definite shades of red, blue, black, white, yellow, 
and green. It is a good thing to have three or more 
samples of each colour so that the child can be asked 
to match them if he does not know their names, and 
each sample of each colour must be of the same shade; 
(h) counting beads, various small toys, or models of 
animals and some bricks or slabs of wood in sufficient 
number for them to be used for addition and subtrac- 
tion; (i) a pencil and paper for the child to write on, 
and various small objects or drawings useful for testing 
the child's knowledge and powers of speech. Great care 
must be taken to choose drawing or models which really 
give a good idea of what they are meant to represent, 
and allowances must be made for the fact that the child 
may not have seen many things or animals which are 
quite common in the experience of other children; (j) a 
set of models similar to those shown in Plate XII. 
The method of using them is described on p. 272 ; (fc) a 
school primer, and some sheets containing large letters 
and simple drawings of animals ; the latter are valuable 
for testing the child's sight, the ordinary test type not 
being of much use because many of the children do not 
know their letters. 

With this apparatus it is not difficult to estimate the 
amount of the child's knowledge, and to gain some idea 
of his mental capacity. Fuller and more elaborate 
tests (see Appendix IV.) may be undertaken later, but 
these are chiefly useful as a record of progress, and are 
difficult if tried before the child has become accustomed 
to be tested and examined. In some American institu- 
tions there is a psychological laboratory, in which a 
trained psychologist carries out regular tests. 

One or two other points are important. 

In the first place each case must be examined 
separately; nothing can be more detrimental to a sue* 
cessful examination than to have several sets of relatives 
and children looking on. 



118 DIAGNOSIS 

The room should be cheerful, well-lighted, and warm. 
Bright objects, such as a metal inch measure or a shining 
tongue depressor, which may frighten or upset the 
child, should not be used. It must be remembered 
that it is a considerable ordeal for a child to be brought 
into a strange room and to be confronted with three 
or four serious-looking people. Though some feeble- 
minded children are too dull and heavy to mind this, 
the majority are by no means so constituted, and unless 
the doctor can gain their confidence he will not be able 
to obtain satisfactory results from his examination. A 
little time has to be spent on taking the history from 
the parents, and during this time the child should be 
allowed to move about apparently unnoticed but be 
quietly watched. The doctor should then ask him the 
names of simple objects or let him match the bricks. 
Once his confidence has been gained it is a more easy 
matter to find out the capacity for writing or reading 
or attempting sums. The measurement of the head and 
the inspection for physical stigmata, the examination of 
the heart and lungs, and finally that of the throat and 
nose can now be made. It is better to reserve until the 
end those examinations which cause most discomfort or 
are most likely to upset the child. These details may 
seem trifling, but they are none the less important, and 
have a good deal to do with the success or failure of the 
examination. 

The following points should be recorded on a case 
sheet such as that shown in Appendix V. : — 

(1) The family history. 

(2) The health of the mother during pregnancy. 

(3) The personal history of the child, including troubles at birth 
and illnesses and the opportunities for mental development. 

(4) The age at which the child began to sit up, walk, talk, 
and to learn to control the bladder and bowels. 

(5) The circumference of the head, the presence or absence of 
physical stigmata, and whether the child belongs to any one of 
the special types. 

(6) The height and weight. 



HISTORY 119 

(7) The speech. 

(8) The sight. 

(9) The hearing. 

(10) The carriage, gait, and ability to join in games. 

(11) The general appearance, bearing, and expression. 

(12) The memory, attention, will, and temperament. 

(13) The powers of reading, writing, calculation, and manual 
skill, and the Standard in which the child is at the time. 

(14) The report as to the way in which the child responds to 
surroundings and how he is treated by other children. 

(15) The teacher's report as to progress at school. 

(16) The parent's report as to usefulness or otherwise in the 
home or for going errands. 

From a consideration of these points one can usually 
come to a conclusion as to whether a child is feeble- 
minded and suitable for admission to a special school or 
institution or not. A certain number of cases have to 
be admitted on probation, but these should not form 
more than a very small proportion of all cases. 

Most of the headings enumerated above have been 
or will be considered in other chapters, but a brief sum- 
mary of the important points connected with each will 
be of advantage. 

(1) A family history of insanity, epilepsy, or mental 
deficiency strengthens the possibility of the child's being 
feebleminded; histories of tuberculosis, alcoholism, or 
syphilis are not so important, though in my experience 
tuberculosis is often a marked feature of the family 
histories of these children. A family history of deaf- 
mutism should be recorded. Near relationship of 
parents and the place of each parent in their family 
should be noted (see p. 181). 

(2) The health, bodily and mental, of the mother 
during 'pregnancy should be noted, because a history 
of physical illness or mental stress is often found. A 
history of mental trouble may point to weak mental 
powers in the mother. Though such conditions pro- 
bably do not of themselves cause feeblemindedness, and 
though it is doubtful whether they have much con- 
tributory effect, still it cannot be denied that ill-health 



120 DIAGNOSIS 

of the mother during the period of development and 
growth of the foetus, which is dependent on her blood for 
nourishment, may have some contributory effect in 
causing abnormal development. Hence the importance 
of obtaining as much reliable statistical evidence as 
possible on the point. 

(3) The personal history of the child may show some 
illness or accident, which has acted as a determining 
factor in producing what we have called secondary 
feeblemindedness. In the same way injuries caused by 
prolonged pressure and congestion of the head at birth 
may have a similar effect. It is not uncommon to 
obtain a history of difficulties at birth or of injury or 
illness acting later; but too much importance must not 
be attached to these factors because parents are very 
prone to attribute their child's failings to some such 
cause. Because they are questioned they often discover 
and exaggerate some trivial illness or accident. Actually 
about 10 per cent, of cases of feeblemindedness are due 
to such secondary causes. 

It is most important to find out what opportunities 
for mental development the child has had. Physical 
illness may have kept him from school or some defect 
such as stammering, deafness, shyness, or nervousness 
may have prevented his making full use of his oppor- 
tunities and have produced a state of backwardness or 
retarded mental development. On the other hand, if 
a child has not improved under careful and individual 
teaching, the future mental development is not likely 
to be good. 

(4) The age at which the child began to sit up, to 
walk, to talk, and to develop control over the bladder 
and bowels should always be ascertained. They are 
very valuable points. Feebleminded children begin to 
walk and talk much later than ordinary children, speech 
being more delayed than walking. An ordinary child 
should sit up at the age of nine months at least, and 



PHYSICAL CHARACTERISTICS 121 

should commence to walk and talk at twelve to fifteen 
months. Control of the bladder and bowels should 
develop during the second year in a well-trained child, 
but it is very late in developing in the mentally defective 
partly because the child learns everything with difficulty 
and possibly because sensation is defective. Other con- 
ditions such as illness or disease may be the cause of 
delayed development of bodily and mental control, but, 
if such conditions can be excluded, the above defects 
are very suggestive. 

(5) The physical characteristics and general configura- 
tion of the child should be examined. It is often possible 
for a practised observer to tell at a glance that the child 
is mentally deficient. There should be little difficulty 
in recognising definite examples of any of the special 
types described in Chapter VI. , but some of the less 
definite examples are not easy to classify. 

The circumference of the head is a very valuable sign, 
and the absence or presence of other physical stigmata 
of degeneration should be noted. We have seen that 
the feebleminded show the physical stigmata of degenera- 
tion more often than do children of normal intelligence, 
while very often a combination of two or more stigmata 
is found to occur in the same child; but it must be 
distinctly understood that such stigmata are not in 
themselves evidence of mental instability. Their pre- 
sence simply points to the inheritance of what is known 
as the neuropathic diathesis. 

The most important stigmata of degeneration are : 
(a) asymmetry and other deformities of the head; (b) 
epicanthic folds at the inner angle of the eye; (c) 
abnormalities in the shape of the external ear; (d) 
abnormalities of the palate and dental arch; (e) an in- 
curving of the terminal joint of the little finger. Many 
of these children also have a coarse skin, and are liable 
to acne and other eruptions. 

(6) Comparisons of the heights and weights of feeble- 



V22 DIAGNOSIS 

minded children with those of ordinary school children 
show that the former are smaller and less well developed 
physically. This is partly due to the fact that they do 
not have the same opportunities for exercise and play, 
but is chiefly an innate defect. The difference is too 
marked to warrant the conclusion that want of exercise 
is the only cause ; and moreover the difference increases 
with age. 

(7) Defective speech is very common, and may be due 
to various causes referred either to the central powers 
in the brain or to poor control over the muscles or to 
defective sensation of the mouth and tongue. Lalling 
or substitution of easy consonants for hard ones is the 
most striking defect. 

(8) The sight must be tested to see whether there is 
any major defect which might possibly account for 
delayed development of the mental faculties. Back- 
wardness may be due to marked degrees of defective 
sight, in which case the child will soon improve with 
treatment; but backward children are not feeble- 
minded. Defective eyesight may, however, enhance the 
original dulness of a feebleminded child, so that allow- 
ance should always be made for it, if it is present. 

Inability to name colours is often found but actual 
colour-blindness is rare, and the majority of children can 
pick out and match similar colours. 

(9) The hearing powers must be carefully tested. 
This is not so easy as might be thought, because 
want of attention or stupidity may simulate deafness 
very closely. The test I usually try is that of dropping 
an article such as a bowl, a penny, or a rattle on to the 
rloor behind the child when its attention is directed else- 
where, great care being taken to be sure that the child 
does not see the article dropping or any movement of 
the person dropping it. However, a child with a want 
of attention so great as to simulate marked deafness is 
usually of too low a grade to be classed as feebleminded. 



PHYSICAL POWERS 123 

Gestures and signs must be avoided. A deaf child of 
normal intelligence is easily distinguished from a feeble- 
minded child by a few simple tests, and even those deaf 
children who, owing to their inability to communicate 
with others, have been neglected and have become queer 
and unresponsive can usually be distinguished from 
feebleminded children. This question is discussed more 
fully on page 129. 

(10) Defects of the general balance and carriage, a 
shuffling gait, slouching, and clumsiness are very com- 
mon, being due to under-development of muscular 
control and lack of mental and physical tone. 

(11) The general appearance, bearing, and expression 
are valuable signs, and, as previously stated, it is often 
possible to tell at a glance that the child is feebleminded. 
The expression on the face, the little mannerisms, the 
lack of featural and muscular control, and the general 
aspect of feebleminded children cannot be denned 
exactly, but to a practical observer there is something 
very characteristic about these points. Of course such 
children differ enormously, some being heavy and dull, 
others apparently quite bright ; but a few minutes spent 
in quietly watching the child, while he moves about and 
handles things, will not be time wasted. 

(12) Perhaps the best simple test of the memory is 
found in the ability of the child to go errands. Another 
good test is to show him a number of articles on a 
tray, and then, while his back is turned, place these 
articles in various visible positions and then ask him to 
find and replace them. Questions may be asked about 
his meals, or if he remembers how he came to the school 
and what he has noticed on the way. These are quite 
valuable points, and will give much information about 
the mental capacity. Some feebleminded children can 
say poetry or songs, but too often this is a mere parrot- 
like repetition. The power of attention is very impor- 
tant for the child's future mental development, and 



124 DIAGNOSIS 

must be carefully noted. This may be tested for by asking 
the child to cross out all the e's or o's in a sentence, or 
asking him to perform some task which needs attention 
for its completion, such as the sorting of snap cards. 
A good test of the reasoning powers is to ask the child 
to put on a coat, which has had the sleeves turned in- 
side out, or to sit on a chair which has been turned 
upside down. The board test described on pages 117 
and 131 is a valuable simple test. The powers of 
association can be simply and rapidly tested by asking 
the child questions about pictures, and in this connec- 
tion it is necessary to find out what opportunities the 
child has had for mental development. Individual and 
skilled instruction makes such a great difference that 
this is a very important point both for diagnosis and 
prognosis. Questions on general knowledge are not of 
much use as tests unless the child has had experience. 
He can be asked to write or draw or do simple sums 
or be given a simple problem to solve, and in most 
instances an idea of his general intelligence can soon be 
formed. Another point that is of great value is whether 
the child is aware of his own shortcomings or not. A 
feebleminded child does not as a rule know that he is 
below the average, and is quite content to remain with 
other feebleminded children. If the child commences to 
babble and talk aimlessly about himself or about any- 
thing that may come under his attention, he is often a 
bad case. The more elaborate series of tests devised 
by Binet and Simon (see p. 253) are of great value 
when time is available, but it is doubtful whether they 
are necessary. Dr. Fernald, from a prolonged experi- 
ence, states that these tests are not very effective in the 
cases in which they are most needed, i.e., cases of slight 
mental defect. In other words, they corroborate where 
corroboration is not needed, and are not decisive where 
decisive tests are needed. He decides that they are 
most useful as aids to teachers in selecting cases for the 



MENTAL POWERS 125 

physician than for the physician himself. He also adds 
that psychological tests cannot be relied on as the sole 
tests, because some cases can pass these tests although 
they are in the light of other data obviously " incapable 
of managing their own affairs." 

(13) Standard at School. — Children generally pass out 
of the infant school at the age of six years and go up 
one standard with each subsequent year; therefore a 
child should be in the First Standard at 6-7 years, the 
Second at 7-8, the Third at 8-9, the Fourth at 9-10, 
the Fifth at 10-11, and so on. The bulk of those suit- 
able for a special school are found in Standards II. and 
III., having been moved up on account of age. Some of 
the better class of the feebleminded are capable of mak- 
ing a fair amount of progress. Dr Fernald gives it as his 
opinion that retardation amounting to three years below 
the age-grade with no handicap of ill-health, etc., is 
strongly suggestive of mental defect. 

The method of reading and writing may help to show 
the character and capacity for sustained effort. Thus 
if a child, on being asked to write a word, scribbles 
aimlessly instead of trying to spell the word, the prog- 
nosis is worse than if he stops and admits that he 
cannot do it. 

Sums, except those of simple addition, are usually 
beyond those who come up for examination, though a 
few may be able to do more in this respect. Feeble- 
minded children do much better with concrete objects 
like beads and bricks, but even then their powers of 
calculation are very small as compared with those of 
ordinary children. 

Finally, it should be again noted that the information 
given by the teachers and parents who have had charge 
of the child is of very great value, and should always 
be placed before the examiner. 

Differential Diagnosis of Feeblemindedness and 
Backwardness. — As previously stated, it is by no 



126 DIAGNOSIS 

means easy to differentiate some cases of dull and back- 
ward children from feebleminded children, and the 
following two cases are quoted to illustrate typical 
examples of each condition. 
Case of Feeblemindedness : — 

A. O., aged 9 years, poor health, cough, easily tired; vacant 
expression ; head circumference 20£ in. ; no deformities ; sight and 
hearing fair; highly arched palate, ears normal; memory, atten- 
tion, and control poor; mischievous; counts to twenty and can 
do very simple addition but no more; cannot read but knows 
letters; can write "cat" but only makes a meaningless scrawl 
in place of his name ; speech defective ; habits somewhat dirty ; 
can dress himself. Family history shows that the mother's father 
died of tuberculosis, and that a twin brother of the mother is 
mentally defective. 

The following is a typical case of Backwardness : — 

A. F., aged 8 years; marked rickety deformities of the limbs 
and stunting; aspect and bearing bright; head circumference 
20i in. ; sight and hearing good; no physical stigmata; memory, 
attention, control, and sense of right and wrong good; slow at 
figures, counts up to twelve, but cannot do abstract calculations, 
not even the simplest addition of figures; cannot read or write; 
speech and habits good; can help to dress himself; has not been 
to school on account of weakness of legs; family history negative. 

These two cases illustrate several points in the differ- 
ential diagnosis of the two conditions very well. 

(1) The family history was positive in the feeble- 
minded child and negative in the backward child. 

(2) The opportunities for mental development had 
been poor in the case of the backward child, and fairly 
good in the case of the feebleminded. 

(3) The general appearance, memory, and attention 
were much better in the backward child : also the 
feebleminded child was mischievous at times, and was 
not of very clean habits : the backward child has not 
learnt to dress himself, because he had been physically 
incapacitated. 

(4) The feebleminded child spoke badly. 

(5) The backward child had never leamt his letters 
or figures, and in consequence could not make any 



IN EARLY LIFE 127 

attempt at reading, writing, or calculation, while the 
feebleminded child, who had had opportunities, could 
make some attempt at addition and writing but was 
far behind the average child ; also he did not fully 
appreciate or admit this fact, but wrote a meaningless 
scrawl for his name. Progress at school is not an in- 
fallible index, and a child may be low in school 
standards and yet have excellent common sense. If he 
can direct his daily doings sensibly he should not be 
classed as mentally defective, even though he be several 
years behind others of his age. Often, however, it is 
necessary to have the child under observation for some 
time, and for this purpose " sorting " classes may be 
of value. 

Mental Deficiency in the Early Years of Life. — 
We shall very briefly discuss here the signs of mental 
deficiency in early life before school age, because it is 
important that such cases should be recognised and 
trained as early as possible. As a rule the diagnosis of 
feeblemindedness is not made during the early years of 
life unless the child belongs to one of the special types, 
and it must be remembered that these types form a 
small minority only. In the greater degrees of mental 
deficiency, idiocy, and imbecility there are often signs 
at an early age that excite the alarm of the parents and 
make them consult a doctor; but in the lesser degrees 
they are less marked, and are not often noticed until 
after the first few years. 

Inability to sit up, lateness in learning to walk and 
talk may excite the alarm of the parents but are put 
down to mere backwardness. Nor is it easy for a 
medical man skilled in the examination of these cases 
to give a definite opinion at an early age. Deafness and 
blindness must be excluded, and a good deal of im- 
portance is to be attached to the response to external 
stimuli and to the vigour and expression of the infant. 
Feebleminded infants neither notice things nor attempt 



128 DIAGNOSIS 

to play, grasp, or babble in the same way as do ordinary 
infants. They may either lie quite still and never com- 
plain, or they may make ugly, fatuous sounds, constantly 
repeat some useless movement, cry out continuously 
without cause, and bang their heads about. The pre- 
sence of many of the stigmata of degeneration, a family 
history of mental affection, small circumference of the 
head, and poor development of control over the bladder, 
bowels, and muscular system are also suggestive points. 
It must be remembered that delayed development of 
function may be due to conditions such as wasting, 
rickets, and other diseases, so that it is not always easy 
to give a diagnosis. 
Cases illustrating such conditions are : — 

(1) F. P., set. 1 year; cannot sit up; head 18 in. On examina- 
tion the back muscles are found to be abnormally weak, and, since 
the child smiles and crows, can shake hands, and has already 
developed some control over the bladder, it is quite evident that 
the inability to sit up is due to some weakness of the muscles 
and that the child is not mentally deficient. This case improved 
rapidly with treatment, and is now normal. 

(2) M. C, set. 1 year; weight 16 lbs. 12 ozs. ; epicanthic folds 
marked ; head 18 in. ; has only just learnt to sit up ; no attempt 
at walking; has said "mamma" and " dadda " and recognises 
parents readily; no signs of control over bladder yet; family 
history negative, no history of convulsions ; child born prematurely 
at 8 months; no spinal disease or deformity present. 

In this Case (2) the fact that the infant can talk and 
recognise its parents is much more important than the 
lateness in developing control of the muscles, so that the 
prognosis of both mental and physical development is 
good. 

The following Case is a marked contrast to Cases 
1 and 2 :— 

(3) A. C, set. 2 years. Brought because she cannot walk or 
talk and seems very irritable. She has attacks of unconsciousness, 
sometimes every half-hour, sometimes once a day. She bites and 
eats anything that she can get hold of, taking pieces out of her 
clothes or out of the tablecloth. There is no family history of 
mental trouble ; the mother is nervous and had a bad shock during 
pregnancy. On examination the most marked symptom /is the 



DEAFNESS AND FEEBLEMINDEDNESS 129 

great want of the power of attention, for though it can be shown 
that the child can hear and see quite well, she does not notice 
loud sounds or bright objects unless they happen to awaken a 
momentary flicker of interest; she gazes aimlessly round with a 
vacant expression, continually moving her head from side to side. 
She cannot walk or talk, and has made no attempt at either. 
There is no sign of any control over the bladder and bowels. She 
resents any examination of her head, which in 18i in. in circum- 
ference. Epicanthic folds are present but the palate is normal. 

In this Case (3) there is no doubt that the child is 
a low-grade case, for in spite of the facts that there is 
no family history, that there are but few physical 
stigmata, and that the patient has a head of fair size, 
it is easy to diagnose mental deficiency from the vacant 
expression due to want of attention, the lateness in 
developing control, the irritability, and the habit of 
biting and eating anything that may come to hand. 

Deafness in Relation to Feeblemindedness. — As a 
hospital physician, I have often had to decide the pro- 
blem as to whether a deaf child is also feebleminded. 
Also at the Royal Schools for the Deaf, Old Trafford, 
Manchester, I have for some years examined the children 
to decide whether they are fit for admission to the schools 
or not. The problem is often a most difficult one, and 
for that reason I shall enter into it rather fully. 

Feebleminded deaf children are those who are not 
endowed with the capacity for normal mental develop- 
ment, and are therefore unable to make much progress 
in any but the simplest methods of communication and 
education, and are, therefore, permanently incapable of 
receiving proper benefit from instruction in ordinary 
schools for the deaf. 

One of the best tests regarding the mentality of a 
deaf child is whether he can learn to speak and to lip- 
read ; but, though a child who cannot learn these powers 
is usually of a lower mental level than a child who can, 
so much depends on the age at which instruction is 
begun, and the nature of the instruction given, that the 
test is not infallible. Many of the children who have 



130 DIAGNOSIS 

to be relegated to the department for sign-instruction 
may show quite a high level of mental capacity. 

The Binet and Simon tests are not suitable for deaf 
children, although many of them are adaptable, and 
some can be used in their original form. Still it is quite 
impossible to compare the mental capacities of normal 
children with those of deaf children by these tests, 
because they involve constant questioning which can 
hardly be done by writing. It is often very difficult to 
explain a test to a deaf child, and to be sure that the 
deaf child knows what is required; and further, deaf 
children are so handicapped by the scantiness of their 
vocabulary that they do not do themselves justice. As 
an illustration of this poverty of expression due to 
defective vocabulary the following responses to the tests 
for supplying to a given list of words other words having 
an opposite meaning are given. Two deaf children of 
good intelligence gave good — bad, heavy — light, white 
— milk, mad — gentle, bright — sunny, clever — stupid, 
and tall — little, wet — fine, rude — girl. Two other deaf 
children of lower mental level gave thin — fat, white — 
chalk, tall — big, and white — colour, false — wicked, 
empty — enough. 

Tests must be conducted as games, and made as 
interesting as possible. Care must also be taken to 
make sure that the child understands what is required 
of him. 

Without attempting to make a complete list, it may 
be of value to give a few of the tests specially applicable 
and useful for deaf children. After noting the powers 
of feeding, dressing, or caring for themselves, the general 
behaviour in the playground and the power of entering 
into games, and giving due consideration to the effect 
that the up-bringing of the child will have had on these 
powers, one can choose the special tests suitable for 
each case. One of the best tests to begin with for small 
children is the board test. Differently shaped blocks 



DEAFNESS AND FEEBLEMINDEDNESS 131 

which have been cut out and made to fit holes cut out 
of a board, are mixed up, and the child is then asked 
to replace them. Some of the blocks must be of similar 
shape but not exactly alike. Naturally training counts 
in this as in any other test, especially if the child has 
been accustomed to do jig-saw puzzles or brick patterns. 
Nevertheless the test is valuable in most cases, first to 
establish confidence, and secondly to show general intelli- 
gence ; it is evidence of more than shyness when children 
try to force a triangular block into a hexagonal hole, 
especially if they have seen others do the test. Other 
suitable tests are (1) replacing the two parts of a card 
cut diagonally; (2) drawing the Binet test figures after 
having seen them once ; (3) counting and counting back- 
wards; (4) counting with beads or nuts or other small 
objects; (5) showing five or more small objects, and 
then, when the child is looking the other way, scatter- 
ing these objects and placing them in visible positions 
within easy reach; the child is then told to turn round 
and replace the objects ; in this manner the visual 
imagery or memory is tested; (6) sending the child on 
errands for several things from different rooms; (7) 
copying drawings ; (8) matching colours ; (9) telling the 
time and imagining the time if the hands of the clock 
should be transposed; (10) writing down words of an 
opposite meaning to a given list of words; (11) educa- 
tional attainments such as writing, reading, arithmetic, 
and manual work. 

With regard to younger children, the poor develop- 
ment of expression on their part, and on the examiner's 
part the difficulty of making himself understood either 
by sign, speech, or writing, add to the difficulties, but 
it is nevertheless usually possible for an expert to find 
out whether the mental capacity is within the normal 
range or not. Sometimes want of docility, wayward- 
ness, or other peculiarities may be very marked because 
the child has been left to itself a great deal or has been 



132 DIAGNOSIS 

ill-treated or neglected. Such children may be very 
difficult to test, and a probationary period combined 
with careful and continuous observation is necessary 
before a definite opinion can be formed. The following 
cases serve to illustrate the points raised above : — 

R. E., set. 13 years, born partially deaf. Dull. Suffers from 
chorea, backward, very poor memory and reasoning power; used 
to have good reports at first; quite fair at sums and adds five, 
four, three, and two in his head ; has attained life-saving 
proficiency in swimming; does not always go errands well, but 
would remember commission given him for next day; would 
know what to do if lost. He has been delayed by illness, and is 
better at manual work than school-room attainments. 

E. M'L, aet. 10 years, born deaf. Dull. Stupid; poor power 
of concentration; weak will; little power of imitation, but is of 
fair general intelligence and does manual work pretty well; is 
improving and is of good appearance and nice character ; can go 
errands and when sent for a hammer brought nails as well. He 
is rather too placid and too easily overborne by other children. 

S. G., aet. 15 years, has a fair amount of hearing power left. 
Marked dulness but hardly feebleminded. Queer and backward; 
speaks badly but has no consonantal defect; very poor at arith- 
metic; can tell the time but cannot do the test of interchanging 
the hands of the clock; adds four, six, seven, five on his fingers 
but not in his head. 

R. S., aet. 9 years. High-grade feebleminded. No interest or 
will power or concentration ; very poor memory and very slow 
progress; powers of association extremely weak; adds and sub- 
tracts five beads but not very well, and also counts a little and can 
write a few words; very poor considering the amount of instruc- 
tion he has had. 

G. S., aet. 14 years. High-grade feebleminded. Did better at 
first but is not doing well now; inconsequent, a chatterbox, very 
careless ; is fairly quick but has no power of concentration ; gets 
lost easily and does not know what to do when lost ; does addition 
and elementary money addition but cannot do division. 

The following case shows how neglect may lead to a 
strangeness of manner and the formation of peculiar 
habits, which may make the child appear feebleminded 
on a cursory examination : — 

D. D., aet. 5 years, born deaf. Has a deformity of the chest, 
a deformed mouth and supernumerary auricles; is subject to a 
facial tic or habit-spasm, and has a defective self-conscious expres- 
sion. She sighs frequently, probably another manifestation of 
habit-spasm ; she can feed herself, and is of clean habits ; the de- 



DEAFNESS AND FEEBLEMINDEDNESS 133 

formity of the mouth should not prevent her from speaking. 
She shows an intelligent interest in birds and animals; does the 
board test well ; does not attempt to use an unsharpened pencil ; 
and though peculiar is evidently not feebleminded or even dull. 
She has evidently been left very much to herself, and her physical 
deformities, defective expression, and peculiar habits are very mis- 
leading. She brightened up considerably after a short stay in 
the school, and will do quite well. 



CHAPTER VIII 

PROGNOSIS 

Assuming that we have already decided that the child 
is feebleminded, we have next to consider the future, 
and also to see if we can to any extent foretell the 
amount of mental development which is likely to take 
place. 

Death Incidence. — Mentally defective persons die at 
an earlier age than is normal, and this characteristic is 
probably more marked in the greater degrees, idiocy 
and imbecility. 

Mongolian imbeciles are liable to sudden death, and, 
generally speaking, imbeciles and feebleminded are 
weaker and less resistant to disease. Also a large num- 
ber of the mentally defective die in infancy before their 
condition is noticed. 

Dr. Still states that in his opinion the mortality in 
mentally deficient children is probably considerably 
higher than that amongst normal children, and that the 
chances of a mentally deficient child reaching adult 
life are definitely less than those of a normal child, 
while Dr. Shuttleworth, quoted by the late Dr. Ireland, 
found that the mortality in mentally deficient children 
is about nine times as great as that of normal children 
in the age periods 5-10, 10-15, 15-20. 

Dr. Tredgold shows that the death-rate is highest 
from 15-20 years, the period in which it is lowest in 
ordinary children. He gives a death-rate of 30 per 1,000 
for aments as compared to 20 per 1,000 for the general 
death-rate. 

134. 



DEATH INCIDENCE 135 

Dr. Barr, from a study of 625 cases, came to the 
conclusion that few pass the 25th year and most die 
between 10 and 20. These conclusions seem to be 
sweeping, but from his table there is little doubt of the 
truth of his inferences, only 83 of the 625 cases being 
alive after 25 years of age. Clark and Stowell find that 
the span of life is curtailed in the " feebleminded and 
idiotic," but that a considerable number live beyond 
the age of 40 years. Of 1,000 deaths of mentally defec- 
tive persons, the maximum number died under the age 
of 25, 30 lived to be over 35, 17 to be over 40, and 4 to 
be over 50. From 1903 to 1911 of 4,275 persons under 
their care (" 2,667 feebleminded and 1,608 idiots ") the 
mortality was 6.5 per cent, in the first group and 19.6 
per cent, in the second. With regard to children, even 
when under the best conditions the mortality was with 
the high grades double that of normal children and with 
the low grades treble that of the high grades. Nearly 
one-fifth of the mentally defective children born die 
under the age of one year. The deaths were caused 
chiefly by infectious diseases, especially pneumonia, 
typhoid, and tuberculosis, though " inanition " was the 
only observable cause in a fair proportion of cases. 
Many mentally defective children succumb very rapidly 
to any acute illness, and it is quite clear that they 
exhibit a diminished physical resistance to infections of 
all kinds and a consequent diminished power of recovery 
from illnesses. This characteristic becomes the more 
marked the lower the grade. Persons merely feeble- 
minded have a longer span of life than the lower 
grades, and this certainly is the experience at Sandle- 
bridge, so that one can say that there is not neces- 
sarily an unusual death-rate in the feebleminded from 
5 to 20 years of age. At Waverley, in America, 
Dr. Fernald has had much the same experience. How- 
ever, good conditions are very often wanting, and there 
is little doubt that the feebleminded tend to be less 



136 PROGNOSIS 

resistant physically to bad conditions than are normal 
children. 

The causes of death in Dr. Barr's cases were phthisis 
121, epilepsy 102, meningitis 42, diseases of the nervous 
system 77, diseases of the digestive system (some of 
which were tuberculous) 109, pneumonia and acute 
infectious diseases 133. The large proportion of deaths 
from phthisis and epilepsy should be noted. Dr. 
Caldecott, quoted by Dr. Still, found that, at the Earls- 
wood Asylum amongst 1,000 consecutive deaths over the 
age of six years, 39.2 per cent, were due to tuberculosis 
(30.5 per cent, of these being due to pulmonary and 
only 1.1 per cent, due to meningeal tuberculosis), 12.4 
per cent, were due to epilepsy, and 10.4 per cent, to 
pneumonia. Clark and Stowell found the death-rate 
from tuberculosis to be 10 per cent. only. 

A great deal depends on the amount of care taken to 
exclude and prevent the spread of phthisis and other 
forms of tuberculosis. The mentally affected often 
come from a stock with a weak resisting power to tuber- 
culosis, so that once this disease obtains a foothold, it 
may spread and do much harm. An open-air life, 
cleanliness, control of milk supply, and exclusion of 
infectious cases are generally effective in keeping this 
disease from obtaining a hold amongst the children. 
Much of the mortality from phthisis in institutions has 
been due to absence of the precautions necessary to 
exclude infection. Where the " soil " and the condi- 
tions are favourable to the disease, an infectious case 
of tuberculosis can do a great deal of harm. But where 
the conditions are unfavourable and proper precautions 
are taken to prevent the spread of infection, not many 
cases occur even though the " soil " is favourable. 

Mental Limitations. — Few duties are more distress- 
ing than that of telling the parents of a feebleminded 
child of the mental limitations and of the impossibility 
of there being any complete cure. It sometimes seems 



MENTAL LIMITATIONS 137 

almost better not to tell them at once, but, sooner or 
later, they must be made to realise that the child can 
never earn its living in the ordinary way, and that they 
should either take steps to put him under efficient and 
lifelong supervision or send him to a good home for the 
feebleminded. Though it is often a very great blow and 
shock at first, it is better for the parents to face the 
difficulty instead of procrastinating and hoping, against 
their better judgment, that at seven years or at fourteen 
years there will be some sudden and wonderful change : 
unfortunately they are often encouraged in these false 
hopes. Once provision has been made and the onus 
of caring for the child has been removed from the 
parents the whole family is benefited. The parents are 
spared the incessant worry of looking after the child, 
the child is better cared for and better educated, and 
the other children of the family are not influenced. A 
feebleminded child often has a degrading influence on 
the rest of the family, and is really very much happier 
in a home with other similar children. 

Probability of Improvement. — Once it is decided 
that feeblemindedness is present, it is useless to shirk 
the fact that the condition is lifelong. Of course it is 
of varying degree, and it is the estimation of the degree 
of defect and the likelihood of improvement that con- 
cern us here. 

It is by no means easy to forecast the future mental 
development, but the points which help us most are : — 

(1) The age at which the child commences to walk 
and talk. 

(2) The type, if the child belongs to one of the special 

types. 

(3) The presence or absence of epilepsy. 

(4) The presence or absence of mental and physical 
defects, including speech defects. 

(5) The general appearance and behaviour. 

(6) The progress made at school. 



138 PROGNOSIS 

The intensity of the neuropathic inheritance seems to 
have little to do with the degree of mental defect, since 
children with the worst family histories are not neces- 
sarily of the lowest grade. Therefore, though a marked 
family history helps us in diagnosis, it is not of much 
value in foreshadowing the possibility of improvement. 

(1) The age at which the child learns to walk and 
talk. — One of the most valuable indications in predict- 
ing the degree of mental deficiency is the age at which 
the child has learned to walk and talk. 

It will be seen from Table III. that the age at which 
the power of control over the muscles develops is later 
in the cases with greater degrees of mental defect, and 
this sign is therefore an important aid to prognosis. 
We have already discussed the causes of this delay. 
The later an infant learns to sit up or to babble, the 
worse, as a general rule, will be the future mental 
development. The normal infant should sit up at nine 
months and babble at ten months. 

Therefore, if a feebleminded child is very late in learn- 
ing to walk or talk he is likely to develop into one of 
the worst cases. Much the same applies to lateness in 
learning to control muscles governing the evacuation of 
the bladder and bowels. 

(2) Type, if any. — If a child belongs to any of the 
special types, the outlook is decidedly worse, with the 
single exception of Cretinism. 

(a) Mongols are generally worse than the average 
feebleminded, though there are a certain number of high- 
grade cases. However, we seldom find that definite 
Mongols are of a high enough grade of intelligence to be 
fit for special schools, and they are more likely to fall 
into the imbecile class. 

(b) Microcephalics are also of a low grade in the 
majority of cases. In a real microcephalic the degree 
of mental defect is usually more or less proportionate 
to the size of the skull, but this is only a general 



CHANCE OF IMPROVEMENT 139 

tendency, and fine distinctions as to the mental capacity 
cannot be drawn from the size of the heads. 

(c) Cerebral Diplegics vary much in their mental 
capacity, but they are usually disappointing in both 
their mental and physical development. Owing to the 
physical infirmities only the slighter cases can attend 
schools. Cerebral diplegia is a condition seen far more 
often in hospital out-patient work than in educational 
or special institutions for the feebleminded. However, 
certain of these and of the Hemiplegic cases improve 
considerably with treatment and care. One child, on 
the left of Plate X., has improved very much mentally 
since he has been occupied daily in turning the mangle, 
and curiously enough his weak and partially paralysed 
arm has improved very much also (see also p. 226). 

(d) Cretinism is a different matter. Here the child 
is mentally deficient because there is no internal secre- 
tion from the thyroid gland, and his whole body is 
suffering from the want of this. Formerly all cretins 
were hopelessly dwarfed in mind and body, but treat- 
ment with extract of sheep's thyroid gland has a most 
remarkable effect. The rapid improvement at first often 
leads to hopes of complete cure mentally and physically. 
Theoretically this should be the case if treatment is 
begun early and kept up; but, practically, a large 
number of cretins which have been treated grow up 
into mentally slow individuals, of a fairly high grade 
it is true, but still definitely slower and less intelligent 
than ordinary persons. One case, E. Y., who has been 
treated practically all her life with remarkable results 
at first, is now well physically but is definitely feeble- 
minded. In her mother's words, " she cannot go 
errands because everyone laughs at her, and she will 
play the 6 softie ' with any little child in the street." 

Case A. was bright mentally but his bodily deformity and 
stunted growth were very marked. Case B. was fairly well 
developed physically and able to wait at table, but she was very 



140 PROGNOSIS 

slow and forgetful in every way. Case N. W. looks bright and 
intelligent, but is smaller and less advanced than her sister, who 
is two years younger. 

Other cases seem to reach almost to the level of 
ordinary mental intelligence, and if they can get employ- 
ment may be capable of earning their own living, but, 
practically speaking, the future mental state of most 
treated cretins is feeblemindedness. 

(3) The presence or absence of Epilepsy, — If an 
epileptic child is also definitely feebleminded, the chance 
of mental and physical improvement depends a good 
deal on the extent and course of the fits. If the fits 
are at all frequent or severe, the child goes downhill in 
mind and body. We shall see that chronic meningitis is 
not uncommon in such cases, and if meningitis is present 
it is easy to understand the progressive deterioration in 
bodily and mental health, and also the difficulty of 
controlling the fits by suitable treatment. If the fits 
can be controlled the child does as well as other feeble- 
minded children do. Fits may reduce a high-grade case 
to a low grade, so that successful treatment of the fits 
usually improves the mental condition; but one must 
never lose sight of the fact that such cases are feeble- 
minded, and in consequence cannot reach the level of 
average intelligence. 

On the other hand, in an epileptic who is dulled but 
not also feebleminded the fits may be stopped and the 
child cured. 

(4) The presence or absence of physical or mental 
defects, 

(a) Physical Stigmata. — The head may vary consider- 
ably in size without giving much indication of the degree 
of mental defect. When dealing with feebleminded 
children of the special school type it is not possible to 
form any definite opinion from the head measurements, 
though of course those with the smallest heads tend to 
be the less intelligent type. This is shown in Table V. 



CHANCE OF IMPROVEMENT 141 

in Appendix II. Still, the children vary a great deal, 
and many of the worst cases have quite large external 
skull measurements. When dealing with Microcephalics 
and Mongols and the greater degrees of mental deficiency 
more reliable information as to future development can 
be obtained from the size of the head. In the same 
way, in infants the size of the head gives a good deal 
of information. 

In estimating the possible mental development the 
head measurements alone must not be relied upon ; they 
are only of use in conjunction with other signs. The 
presence or absence of the deformities of the ears, palate, 
eyelids, and other parts helps to some extent, tending 
to be more common and of greater degree in the worst 
cases. But this again is only the general tendency, 
and many exceptions occur. Prognathism or protruding 
lower jaw gives the appearance of a dull heavy type, 
but such cases are often of a higher grade than one 
would expect. 

(b) Mental Stigmata. — Pica, or the habit of eating 
dirt, coal, and other repulsive things, belongs more 
especially to the lower grades of mental deficiency, and 
should therefore be taken as being a bad sign. Other 
depraved and disgusting habits have much the same 
meaning. Bulimia or inordinate eating is partly due to 
defective sensation from the stomach and partly to want 
of restraint. 

(c) Speech. — Speech defects are more common in the 
worst cases, but it is doubtful whether they have actually 
much effect in preventing progress in mental develop- 
ment. The child can usually make himself understood 
and can understand others, the only difference being 
that he may be more silent, and in children of normal 
intelligence speech defects have no great effect in retard- 
ing mental development. 

(5) General appearance and behaviour. — Of course a 
great deal depends on the powers of voluntary and sus- 



142 PROGNOSIS 

tained attention and on the temperament. It is very 
difficult to get any results with children who cannot 
give sustained attention, and in making an estimation 
of the probable future mental development one must 
consider these powers carefully. Many apparently 
bright children make little progress because their atten- 
tion is so easily diverted from one subject to another, 
and it may be the more stolid and unemotional children 
that improve most. 

The absence of natural modesty is a bad sign, and is 
more evident in the lower-grade cases. In the same 
way, if a child cannot be taught to wash, though physi- 
cally able to do so, it generally indicates a fairly marked 
degree of defect. A child fit for an institution for the 
feebleminded should be able to learn in at least six 
weeks that personal cleanliness is important and how to 
keep clean. Of course many ordinary children do not 
easily learn to keep themselves clean, but in an institu- 
tion much importance should be given to personal 
cleanliness, and a great deal can be learnt of the child's 
mental powers by the amount of response he makes to 
efforts to teach him such matters. They should also be 
able to feed themselves ; at first there is often some 
trouble with this, but one can soon judge whether the 
child will learn quickly or not. If a child cannot feed 
itself and there is no deformity or disease, the mental 
powers are likely to be very poor. 

It is not difficult to eradicate the habit of masturba- 
tion if the child is young and if cleanliness, wholesome, 
plain food with the minimum amount of meat necessary, 
and plenty of physical exercise are enforced. The 
feebleminded are easily led astray by a bad example, and 
bad habits spread by imitation. They are also as a 
rule amenable to discipline, so that, given absence of bad 
examples and good conditions with plenty of occupation 
to produce healthy tiredness, bad habits can be reduced 
to a small minimum. 



MORAL DEFECTIVES 143 

It is well to emphasise here the importance of ad- 
mitting the children at an early age before they have 
acquired bad habits or bad characteristics ; also one can 
see how very necessary it is for these children, if they 
are to avoid degrading conditions, not to lie fallow in 
mind and body. 

Future of Moral Defectives. — The progress of cases 
which show moral failings is often very discouraging. 
Punishment has but a temporary effect on the majority, 
and the only way to prevent what is apparently an 
ineradicable defect is to keep the child out of tempta- 
tion. Such cases may be very difficult to deal with in 
an institution, for they cannot be isolated and their 
influence on the other children is sometimes very bad. 
.The prognosis in these cases is decidedly bad as regards 
their especial failing, though generally they are of high 
grade. Recent experience has shown that it is extremely 
important that they should be recognised and suitably 
controlled. At the State institutions there are already 
a number of girls who have been educated in Day 
Special Schools, and then turned out only to come under 
care as violent and dangerous criminal defectives. How- 
ever, true examples are not very common, and if they 
come under discipline early they can generally be suffi- 
ciently controlled to allow of their residence in a colony. 
(6) Progress at School. — Progress in learning to read, 
write, and calculate is of considerable value in the esti- 
mation of the degree and nature of the defect or of 
the amount of improvement to be expected. It must 
always be remembered, however, that these are educa- 
tional attainments, and, as such, are often defective in 
children not feebleminded but only backward. 

Feebleminded children are not good at school work, 
and, though the school teacher can form a fairly correct 
estimate of the mental capacities, some cases do sur- 
prisingly well at outdoor work when they are quite 
hopeless in the school-room (see p. 233). 



144 PROGNOSIS 

It is very difficult to draw a line between the lowest 
grade of feeblemindedness and the imbeciles. In an 
institution for the feebleminded there are always a 
certain number of doubtful cases, who may have to be 
discharged as being of too low a grade ; but, as we have 
said before, some congenial occupation may do a great 
deal even for the worst cases. 

Some small responsibility or charge may give infinite 
pleasure to these simple minds, and a case should not 
be given up as hopeless until everything has been tried. 

In early life much information can be obtained from 
watching whether the child plays and notices things 
going on around him, from his attitude and expression, 
and from his general appearance and actions, while later 
there are the other signs; but it is difficult to give 
definite rules, because large and varied experience alone 
enables one to predict the future mental development 
of the feebleminded child with any degree of accuracy. 

Of one thing, however, it is always possible to speak 
with no uncertain voice — if the child is feebleminded, he 
or she can never rise to the mental level of the ordinary 
child, and should never be abandoned to earn his or her 
own living. Therefore, though in many cases it is 
possible to raise the child to a level high enough to 
enable him to do useful work under supervision, he 
should never pass from the immediate care of persons 
capable of guarding and guiding, what is likely to be a 
precarious and irresponsible lifetime. 



CHAPTER IX 

TREATMENT AND CARE 

The methods of treatment and training in institutions 
and schools are so excellently and so fully given by Miss 
Dendy in Appendix I. that it is not necessary to do 
more in this chapter than to refer to the medical aspects 
of the care of feebleminded children. 

We must realise that in dealing with feebleminded 
children we are dealing with children who are consider- 
ably below the average in mental development and who 
can never attain to that average. We must under- 
stand that this failure of mental development is more 
or less uneven, so that some children are especially defi- 
cient in one mental quality, others in another, and that 
no two cases are exactly alike. It follows that treatment 
and training must be conducted on both individual and 
general lines. Further, we must realise that many of 
these children, though they cannot be brought up to 
the normal, can be considerably improved mentally and 
physically. In some cases it is necessary to begin with 
the very simplest exercises, such as handling pieces of 
wood and adjusting them to similarly shaped holes, and 
then gradually to take the child on to harder ones, any 
occupation being better than none. Tasks that give the 
children some concrete and definite object to work with 
are the best, since the difficulty of gaining and fixing 
the attention is perhaps the greatest bar to successful 
teaching. 

Those who are engaged in work of this nature should 
not be disheartened if no benefit is immediately appa- 
ll 145 



146 TREATMENT AND CARE 

rent, because progress is often very slow, and such work 
calls for a great amount of patience and perseverance. 

Treatment of a Feebleminded Child at Home. — 
Good habits, personal cleanliness, neatness and tidiness 
in clothes and rooms are things to be taught first. The 
child must not have everything done for it, a point that 
is very important as regards attention to personal needs. 
Want of cleanliness or absence of control over the 
bladder and bowels may be tolerable in a child of three 
years, but becomes much more disagreeable and trouble- 
some as the child grows older, and good habits can best 
be taught if training is begun early. The child should be 
taught how to feed himself, and, since many feeble- 
minded children have a tendency to over-eat or to bolt 
their food, careful training is necessary to prevent diges- 
tive disturbances, such as furred tongue, foul breath, 
and irregularity of the bowels. 

With a judicious mixture of kindness and firmness, 
much can be done to improve the mental and physical 
state of the child. Constant occupation, discipline, and 
cleanliness should eliminate bad habits, and the child 
must be protected from association with persons likely 
to have a bad influence on him. Feebleminded children 
are much more easily upset than are ordinary children; 
consequently careless or ignorant visitors may, quite 
unwittingly, undo in a short time what it has taken 
weeks to teach. 

Little responsibilities such as the care of a small patch 
of garden add greatly to the child's pleasure, and it 
should not be difficult to make him happy. There is no 
doubt that the company of other children of a similar 
mental calibre is an advantage rather than a disadvan- 
tage, discipline being more easily maintained under these 
circumstances and the children being much more cheerful 
and more easily amused. Furthermore, they make 
great friends with animals, so that dogs form very good 
companions and playmates, 



SPECIAL SCHOOLS 147 

Open-air exercise and drill or games for developing 
the control of their muscles are quite as important for 
them as for ordinary children. The games chosen 
should be ball games, such as football or tennis, battle- 
dore and shuttlecock, skipping, and in fact any of the 
ordinary games suited to training hand and eye to work 
together in co-ordination. Many feebleminded children 
need a good deal of stimulation to make them play or 
work, and it is very necessary to prevent them from 
simply sitting still gazing vacantly at nothing and per- 
haps rocking to and fro. Such characteristics are more 
marked in the worst cases, but in all cases precautions 
must be taken to prevent mental vacancy, the company 
of their fellows being one of the best remedies. 

The treatment of bed-wetting is discussed later (p. 150). 

Special Schools and Institutions. — The children are 
chiefly selected from those attending ordinary schools 
or from other cases recommended to the education 
authorities. 

In Appendix V. are given the statutory forms and 
certificates. The form should be filled up at the 
examination of the child, but it is often impossible to 
get a reliable history at once. A reliable history is very 
valuable, and it is worth while to go to some trouble 
to verify, and correct if necessary, the points filled in 
at the time of the examination of the child. At the 
Royal Albert Asylum, Lancaster, the parents are given 
two forms — the first is a model filled in as a guide; 
the second is blank, and on it they are asked to fill in 
the particulars regarding their child when they have 
had time to collect evidence. They are also given a 
form to be filled in by the family medical attendant. 
The certificate must be filled in by the medical officer 
as soon as the diagnosis of feeblemindedness has been 
made. 

The school hours should be arranged so that the times 
of opening and closing do not coincide with those of the 



148 TREATMENT AND CARE 

ordinary day-schools, in order to prevent other children 
from bullying and teasing the feebleminded. 

The hygiene of these schools is much the same as 
that of others, regular bathing, cleanliness, and neatness 
being especially important. Consequently it is neces- 
sary that the schools should be provided with good 
baths, and that the children should be made to bathe 
once a week. Each school should have two sets of hot 
and cold water baths in separate rooms, one for 
boys and one for girls. It is important to note that 
the baths should be shallow, of the " slopstone " 
variety, a depth of eighteen inches being sufficient. 
They should be of glazed brick, set into the floor, and 
large enough to accommodate four or five children at 
a time. A bath attendant is needed, and the caretaker 
of the school and his wife may be suitable for this duty. 
Lighting and heating and good airy cloakrooms are just 
as necessary as in ordinary schools, and a large central 
hall is essential for drill and exercises. The playgrounds 
should fulfil the usual requirements. 

Physical drill is very necessary, and there should be 
frequent breaks in lessons for the purpose of marching, 
skipping, or other exercises. Rhythm and swing are 
important, so that music is a valuable asset. It is 
fortunate in this connection that feebleminded children 
have an especial liking for music, which attracts and 
fixes their attention more than anything else. Drill 
must not be too arduous, because it must be remembered 
that feebleminded are weaker than ordinary children; 
moreover, they cannot concentrate on any one subject 
for long, and need, therefore, a greater variety in drill 
or lessons. 

Individual teaching is very important; each child 
should be known and his various failings noted, 
analysed, and corrected by special instruction if neces- 
sary. For this reason classes should be as small as 
possible, the maximum number of children being 



EYES, NOSE AND TEETH 149 

twenty* (and for manual and domestic subjects fifteen), 
and the class-rooms built on this scale. It is remark- 
able how these children improve at first, when the 
special efforts made to gain their attention and the 
individual teaching begin to have an effect. Specially 
trained teachers are needed, and one teacher is required 
for each class exclusive of the principal teacher. 

One great advantage of special schools to feeble- 
minded children is that, though not always conscious 
of their mental infirmity, they are often bullied and 
teased in the ordinary schools, while in addition they 
cannot have that special care and skilled instruction 
which is so necessary for the development of their 
crippled faculties. Instead of suffering from contact 
with other children of the same class, they are distinctly 
benefited by such association, for they lose any feeling 
of being behindhand, if such ever existed, and many of 
the higher grades are decidedly improved by being able 
to help others of a lower mental capacity. 

Care of the Eyes, Ears, Teeth, Nose, and Throat. — 
The care of the eyes, ears and teeth is important. 
There is no doubt that the feebleminded are less resis- 
tant to disease, so that ear trouble is not uncommon 
and minor defects may become much worse for want 
of proper care. 

Care of the mouth and teeth is very necessary, be- 
cause bad teeth form convenient portals for the entry 
of disease besides leading to imperfect mastication and to 

*A book of regulations is published by the Board of Education, 
and can be obtained from any bookseller or directly from H.M. 
Stationery Office at London, Manchester, Cardiff, or Edinburgh. 
The regulations are brought up to 1920, and contain instructions 
as to teaching, building regulations, grants, and other items regu- 
lating the conduct of Special Schools. Price 3d. net (Cmd. 617). 
The Annual Reports of the Chief Medical Officer to the Board of 
Education should also be read, and the Board of Control have 
issued " Suggestions for School Organisation and Classification in 
Institutions for the Mentally Defective " for the use of those who 
have opened or are about to open Training Schools and Colonies 
for the mentally defective. 



150 TREATMENT AND CARE 

indigestion. The teeth should be cleaned morning and 
evening, the evening cleaning being the most important. 
It is a good plan to have the services of an ophthalmic, 
an aural and a dental surgeon available for institutions, 
and special school cases can be sent to their own medical 
men or to hospitals. 

Enlarged tonsils and adenoids should certainly be re- 
moved, because they lower the general health, give rise 
to catarrh and to poor chest development and to deaf- 
ness, in addition to any dulling effect they may have on 
the mental powers. 

Feebleminded children bear operations quite well, ex- 
cept one of the special types, the Mongols. However, even 
with these the peculiarity is not sufficiently well marked 
to prevent operations necessary for their well-being. 

Control of the Bladder and Bowels. — Bed-wetting 
is generally remedied by disciplinary measures, though 
it must always be kept in mind that some children 
suffer from this complaint because of abnormal condi- 
tions of the urine or urinary organs, or because they 
have large tonsils and adenoids. A nocturnal epileptic 
fit may also be a cause. These cases, however, are 
exceptional, and even apparently hopeless cases may 
yield to treatment on general hygienic lines. Such 
treatment is as follows : — 

The bed should not be soft, and the bed clothes must 
not be heavier than is necessary for warmth; light bed 
clothes and a firm mattress are far better for the child 
in every way. The child should not be given anything 
to eat or drink for two hours before going to bed, and 
should have as little fluid as possible with the last meal. 
There is no need to restrict the total amount of fluids 
unless it is excessive, but it should be taken early in 
the day. About an hour after going to bed the child 
should be wakened and made to empty the bladder. 
If these measures are not successful medicinal treatment 
with belladonna may be necessary; but enuresis or 



FITS 151 

nocturnal incontinence is to a great extent a habit, 
which, if once broken for any length of time, is not very- 
liable to recur. 

There is not usually much difficulty in training these 
children to exercise control over the bowels when they 
are under supervision, and only the lower-grade cases 
give much trouble. 

There is, however, a good deal of difficulty in ensuring 
that the children have a daily evacuation of the bowels. 
Regularity in this respect is very important for their 
health and mental well-being, constipation making them 
duller, more irritable, and more difficult to deal with, 
while, if the child is epileptic, constipation will increase 
the liability to fits. Care should be taken therefore to 
make a point of exercising a supervision over the daily 
habits. In this connection it should be pointed out that 
many of the troubles connected with the digestive organs 
may arise from imperfect mastication or bolting of 
food; also that such children may pick up and eat 
indigestible things of all sorts. For these reasons furred 
tongue, foul breath, constipation, or diarrhoea are com- 
mon and give considerable trouble. 

Fits. — It is necessary to distinguish between epileptic 
fits and fits due to hysteria, and it is by no means easy 
to do so in a fair proportion of cases. Amongst feeble- 
minded children epileptic fits are far more common than 
hysterical fits, which occur chiefly in girls. The main 
points of distinction are that the child with epileptic fits 
loses consciousness, often bites his tongue, and hurts 
himself in falling ; the movements during the fit are pur- 
poseless, and the urine may be passed or the bowels 
opened while the child is unconscious. There may also 
be a family history of epilepsy, and the commencement 
of the fits usually dates from early childhood. A child 
suffering from hysterical fits is often nervous and 
excitable; the fits may be very real, but there is not 
the same loss of consciousness as in epilepsy, the tongue 



152 TREATMENT AND CARE 

is never bitten, nor does the child hurt herself in failing. 
The fit may be stopped or averted by a sudden shock 
or surprise, and often occurs when it is likely to attract 
attention. However, it is not always easy to differenti- 
ate the two conditions, and it must not be forgotten 
that a combination of the two, known as hystero- 
epilepsy, may occur. The treatment of hysterical fits 
consists of firm, but not harsh, disciplinary measures, 
the discouragement of any morbid desire for sympathy, 
and of measures calculated to improve the general health 
and to occupy the child's mind. 

The following is a case of hysteria : — 

E.C., aged 6 years; family history negative; had a bad fall 
and was burnt one year ago; good habits and bright mentally; 
has fits several times a day; has fits if she cannot get her own 
way; the fits can sometimes be prevented by making her run; 
she always falls gently, and has never bitten her tongue nor 
hurt herself nor passed urine during the fits; if given anything 
nasty during the fit she spits it out. 

Epileptic fits, especially if they are frequent, may 
have a great dulling effect, so that it is necessary to 
prevent them as much as possible. Quite a large pro- 
portion of feebleminded children suffer from these fits, 
so that there are always several and sometimes many 
cases to be found in institutions. An outdoor life with 
regular and a not too stimulating diet has a very great 
effect in reducing the number of the fits and may even 
cure them. A child with fits should therefore be put to 
some outdoor work; but not where there would be any 
danger if he suddenly fell down in a fit. Regulation of 
the bowels is very important in these cases, and if 
bromides are ordered care must be taken to counteract 
their constipating effect by the addition of some laxative 
such as tincture of rhubarb. Bromides have to be used 
fairly often to counteract both fits and mere excitability 
or irritation apart from fits, but they can only be given 
under medical supervision. Borax is also a valuable 
remedy. Some cases with bad fits are very intractable, 



HEART AND CIRCULATION 153 

neither medicinal nor other remedies having any effect; 
the child gradually goes downhill mentally and physi- 
cally. In some of these cases there may be a chronic 
meningitis. An isolated fit, which seems to be epileptic 
in nature, may occur at some epoch such as dentition 
or puberty. 

Thyroid Extract. — In cretinism, Thyroid Extract is 
essential, and its effect and methods of use have been 
already described in Chapter V. But a certain number 
of cases that are not cretins seem to suffer from a small 
amount of thyroid deficiency, so that improvement 
takes place under treatment with small doses. This 
improvement is, however, usually only slight and 
temporary. 

Heart and Circulation. — The weakness of the flow 
of blood shown by the cold extremities and other circu- 
latory disturbances common in feebleminded children 
renders them less resistant to the effects of exposure 
and also very liable to chilblains and kindred affections. 
Consequently it is important to guard against undue 
exposure, and to make their clothing and boots suitable. 
But this weakness must not be made an excuse for non- 
attendance at drill or work unless there is some trouble 
which really incapacitates the child. Judicious exercise 
and work can do much to improve the child and inure 
him to the effects of variations of temperature. 

In this connection the question of bathing and douch- 
ing must be considered. Douching and variations in 
temperature are good in that they give exercise to the 
powers of contraction and dilatation of the blood-vessels 
near the skin : it is the activity of these vessels which 
enables a person to resist the effects of variations of 
temperature. Therefore douching and exercise designed 
to stimulate these powers are good for the child so long 
as they are judiciously applied and are not pushed too 
far. Such treatment must be begun gradually and 
increased as the activity of the skin blood-vessels 



154 TREATMENT AND CARE 

increases. There is no doubt that some cases benefit 
considerably from judicious hardening measures, but it 
must always be remembered that these children have 
very poor circulations, and such measures should never 
be overdone. 

Tuberculosis. — One of the most important points in 
the care of feebleminded children in institutions is the 
prevention of tuberculosis. There is little doubt that 
such children offer a weaker resistance to tuberculosis, 
and in some institutions there have been a large number 
of deaths from this cause. If the disease once obtains 
a foothold and finds favourable conditions it may spread 
rapidly, but by efficient ventilation and lighting and by 
providing the children with a vigorous outdoor life a 
great deal can be done to prevent its progress. 

It must be understood that tuberculosis is due to a 
germ, which may be spread by the dried sputum of a 
person suffering from consumption or by infected milk 
or meat. Therefore supervision must be exercised over 
all persons, teachers, nurses, and attendants, who come 
into contact with the children, and children with active 
lung disease should be excluded. The milk (and but- 
ter) and meat must be free from infection with the 
germ, which may find its way into them either because 
the animal from which they have been obtained is 
tuberculous or from accidental infection by dust or 
handling during transit. 

It must not be forgotten that some children may 
have the disease in a quiescent form, and that it may at 
any time be stirred into fresh activity by illness; a 
watch must, therefore, be kept for any such cases. 

Experience at Sandlebridge and Waverley proves that 
if the above measures are adopted and thoroughly 
carried out cases of tuberculosis should be exceptional 
in institutions for the feebleminded. 

The Infectious Diseases. — Since outbreaks or isolated 
cases of infectious disease may occur in schools, homes, 



INFECTION 155 

or institutions, it is well to make preparations for deal« 
ing promptly with such cases. In many instances it is 
possible to send the child to the local hospital for infec- 
tious disease, but if possible it is a good thing to have 
isolation rooms or an isolation hospital available, where 
a child can be kept until he can be removed, or where 
doubtful cases can be kept under observation. 

Modes of Infection. — The infectious diseases are all 
due to agents which may find entry to the body by 
being inhaled or swallowed, or by lodging in the nose 
or throat. The discharges from the body (especially 
those from the nose, throat, mouth, and ear) of a per- 
son suffering from one of these diseases are infectious, 
so that the clothes, towels, cups, and other articles used 
by them may carry the disease. Infection may be intro- 
duced by visitors or a nurse ; a teacher or an attendant 
may carry the germs from one child to another, or a 
farm-hand or other person, suffering from the disease, 
may infect the milk or food. If the child's health is in 
a low state when he is exposed to the disease he is more 
likely to be affected, but the infectious diseases may 
attack children in good or bad health. 

Since the clothes can carry germs, it is necessary to 
provide good airy cloak-rooms at schools, and at all 
times to see that the clothes have a good opportunity 
of ventilating and drying. The children should, as far 
as possible, use their own towels, drinking cups, brushes, 
and other utensils, while unnecessary games, habits, or 
customs likely to facilitate the spread of disease from 
child to child should be discouraged. 

Disinfection. — Fresh air and sunlight are the best of 
disinfectants, few germs being able to live long under 
such conditions, hence the value of thorough ventila- 
tion, well-lighted rooms, and of open-air games and 
exercises. 

When a case of infectious disease has occurred it is 
necessary to disinfect all articles that have been in the 



156 TREATMENT AND CARE 

room in which the child has been isolated. The smaller 
articles, which should be as few as possible, can be 
removed and suitably disinfected, and a sulphur candle 
can be burnt in the room itself to disinfect the walls 
and larger pieces of furniture. A spray of formalin 1-2 
per cent, is useful and effective. Other useful disinfec- 
tants are carbolic acid, lysol, creasol, and chloride of 
lime. Heat is the best disinfectant of all, so that boil- 
ing or stoving is the surest method of disinfecting such 
articles as can be boiled or heated. Other large articles 
can be sprayed or sponged, and then placed out in the 
open-air and sunlight. 

The Characteristics of Infectious Diseases. — The 
infectious fevers generally begin with feverishness, flush- 
ing of the face, general malaise, headache, vomiting, 
sore throat, and a rapid pulse. Later the rash comes 
out, but since most cases are infectious before the rash 
appears, it is important to isolate them early. These 
diseases have a period of incubation, which is the period 
between infection and the appearance of the symptoms, 
and it is important to appreciate this, because, when 
a case has occurred and been removed, other cases 
may be incubating and may arise at any time during 
the incubation period of that particular disease. The 
period of quarantine is that during which cases which 
have been exposed to infection may develop the disease. 
The feverish stage usually lasts for some days, and is 
followed by the period of convalescence, during which 
the child may be liable to the after-effects of the disease 
and consequently need supervision. The following are 
very brief descriptions of the common infectious 
diseases :— 

Scarlet Fever (Scarlatina). — The incubation period is from 2-5 
days and the quarantine period 14 days ; the illness begins with 
headache, vomiting, sore throat, and a rapid pulse; the tongue is 
furred, and is said to resemble a strawberry in appearance; the 
rash is a diffuse bright red blush, and appears first on the chest 
and face; it is important to understand that scarlet fever may 



INFECTIOUS DISEASES 157 

occur without a rash or that the rash may be overlooked, the only 
prominent symptom being sore throat ; the temperature is usually 
raised up to 102 deg. or higher, and, later on, peeling of the skin 
occurs, so that it is important to look for peeling and sore throats 
if scarlet fever is epidemic. Anaemia, ear disease, and kidney 
disease are common after-effects, so that children who have had 
an attack must be watched for such complications. The period of 
exclusion from school after an attack is six weeks from the onset, 
if all discharges from the nose, ear, and throat have ceased. 

Measles. — Measles is a very common and in itself a less serious 
disease than scarlet fever, but its after-effects are very bad, and 
it is responsible for much tuberculosis and pneumonia. The 
incubation period is usually about twelve days but may be three 
weeks, and the quarantine period is three weeks; the disease 
begins with running at the eyes and nose, redness of the eyes, 
and cough; the temperature rises, and the child is extremely un- 
comfortable till the rash comes out; the rash is a blotchy, dusky 
red eruption, and first appears behind the ears; spots may be 
found inside the cheeks before the rash appears, and these are 
valuable for diagnosing cases early when an epidemic is rife, but 
they are not very easy to recognise ; the period of exclusion is 
4-5 weeks, and cases should be watched for cough or wasting, or 
other signs of tuberculosis. 

Mumps. — In this disease there is inflammation of the parotid 
gland, a gland that lies in the neck just below the ear; the 
disease is very infectious, and may give considerable trouble in 
schools; the incubation and quarantine periods are both 3 weeks; 
the onset is characterised by painful swelling of the parotid 
gland, difficulty in swallowing, and some feverishness ; the swell- 
ing may go down rapidly but the case is still infectious, and the 
period of exclusion is 4 weeks or longer if the swelling persists; 
the swelling is just below the ear and over the angle of the jaw, 
and must not be confused with the swelling of the glands lower 
down and further back, which are often swollen if the tonsil is 
inflamed. 

German Measles. — This disease is much less serious than measles 
but epidemics occur in schools; it is almost intermediate between 
scarlet fever and measles in some ways, the rash being of tiny 
red spots, which are not so blotchy as those of measles, nor is 
the rash so diffuse as that of scarlet fever; cases vary very much, 
and sometimes there is hardly any rash at all ; the incubation 
period is 14 days. The disease is usually a very mild one, and 
chiefly gives trouble on account of the difficulty of distinguishing 
it from scarlet fever or measles; the periods of quarantine and 
exclusion are 3 weeks each. 

Diphtheria. — This is not a fever but a localised disease of the 
throat with general symptoms due to the poisons absorbed from 
the inflamed throat. It is very infectious, and the incubation 
period is 1-5 days; the child first begins with hoarseness, sore 
throat, a brassy, barking cough, difficulty in swallowing and 



158 TREATMENT AND CARE 

symptoms of general illness, but the temperature is not high as 
a rule. On looking at the throat a whitish membrane is seen 
adhering firmly to the tonsils and perhaps spreading to the 
palate; the disease may also affect the nose or the lower parts 
of the throat, and in either of these cases no membrane can be 
seen; difficulty of breathing may develop owing to the blocking 
of the air passages by the membrane. The best treatment for such 
cases is a dose of anti-diphtheritic serum given under the skin, 
and often this injection has to be given as a preventative to 
persons who have been exposed to infection ; the quarantine period 
is 14 days and the period of exclusion 6 weeks or until all dis- 
charges have ceased and the throat swabs are negative; some- 
times cases of nose diphtheria with chronic discharge are overlooked 
or allowed to come back to school, and may be the cause of fresh 
cases of the disease. The after-effects are anaemia, weakness and 
paralysis of certain parts, such as the palate, the legs, the eye- 
muscles, and the heart, due to the poisoning of the nerves; in con- 
sequence children who have had diphtheria must be watched for 
paralysis and for heart weakness. 

There are other causes of sore throat such as rheuma- 
tism, influenza, and follicular tonsillitis, but a sore 
throat must always be regarded with suspicion and a 
watch kept for the appearance of a rash or of a membrane. 

Conjunctivitis. — " Cold in the eye " or inflammation of the mem- 
brane lining the eyelids and covering the front of the eyeball may 
occur in epidemic form in children. The discharge from the eyes 
is usually very infectious, being carried from one child to another 
by soiled towels, handkerchiefs, hands, clothes, and other means. 
A lowered state of health, rheumatism, and other diseases, or the 
presence of a particle of dust or grit, may be the cause of the 
isolated cases. If the inflammation is limited to the conjunctiva 
and does not cause ulceration of the cornea (which is the trans- 
parent membrane in front of the pupil), there is not much danger 
to sight, but the possibility of the presence of such an ulcer must 
always be borne in mind, and no cases should be neglected. Con- 
junctivitis, though not always actually painful, usually gives rise 
to much discomfort, and the discharge may become purulent and 
copious. Frequent bathing with boracic, alum, or other astringent 
lotions and with warm water is necessary, and the use of yellow 
oxide of mercury ointment at night-time will usually prevent the 
eyelids from sticking together. The general health should receive 
attention, and strict measures must be taken to prevent the spread 
of infection, any cloths contaminated with the discharge being 
burned or well boiled and the case or cases being isolated if 
necessary. 

Ringworm. — Ringworm is a disease which most commonly affects 
the scalp, but may attack the skin of the body or limbs. It 



CONTAGIOUS DISEASES 159 

spreads from one child to another by actual contact or by infected 
caps or brushes. The disease is caused by a fungus which attacks 
the hair, causing it to become brittle and break off. The fungus 
extends down to the root of the hair, so that the part left in the 
head is still infected. The diseased areas take the form of rings 
which appear as baldish patches, showing a sparse stubble of 
broken-off hairs. If on the skin of the body the fungus forms 
circles, more or less complete, marked out by a reddened line. 
If left to itself the disease persists for months or years. 

The treatment of ringworm of the scalp is rendered difficult 
because the fungus is deep down in the roots of the hair and 
cannot be readily reached. The hair should be cut off close over 
and round the patch and a careful inspection made for other 
diseased areas, which are generally more numerous than was at 
first suspected. The hair must then be washed with carbolic soap 
and an ointment of oleate of mercury (5-10 per cent.) should be 
applied, the rest of the scalp being rubbed with carbolic oil. 
The treatment needs considerable patience, and must be continued 
for some time. When the fungi have been killed the hair begins 
to grow again. Some cases are very difficult to cure, because the 
ointment does not reach the roots of the hair, and in such cases 
the best results are obtained by applying irritants that cause 
inflammation and so destroy the fungi or by suitable x-ray treat- 
ment. 

Though treatment has to be continued for some time, there is 
not much likelihood of the disease spreading to other children 
after one or two thorough applications of mercurial ointment have 
been made; therefore isolation is not necessary when treatment 
has been carried on for a day or two, if a cap is worn and pre- 
cautions re brushes, etc., are taken. 

Pediculosis. — Pediculosis or lice in the head is a very common 
and disagreeable affection. The pediculi lodge in the hair of the 
head, most commonly over the ears, and lay their eggs as nits 
on the hair. The lice cause a good deal of irritation, so that, 
through scratching, sore places, scabs, and matting of the hair 
are often present. The glands at the back of the neck may be- 
come enlarged, and there may also be a considerable degree of 
anaemia and irritability. Pediculosis chiefly affects girls because 
they have long hair, and, since the lice pass very readily from 
one girl to another, one infected head, if overlooked, may be the 
cause of a large outbreak. Since children may be infected anew 
from visitors or other persons, it is necessary to keep a sharp 
look out for such cases. Practically in institutions it is better to 
arrange for all the girls to have their hair cut short and to keep 
it so. 

The treatment of pediculosis is really quite simple if under- 
taken systematically and thoroughly. First the lice must be 
killed. If the head is not very sore, a thorough washing with 
methylated spirit will effect this or a compress of lint that has 
been soaked in carbolic lotion (1 in 20) is equally efficient if left 



160 TREATMENT AND CARE 

on all night. Neither of these measures affect the nits or eggs 
on the hair, so that if nothing further is done these hatch out 
and give rise to fresh trouble. The most effective and ready way 
of killing the nits is to soak and comb the hair through with Oil 
of Sassafras, which, though it has a powerful smell, is not un- 
pleasant. 

If this application is made thoroughly for three successive days, 
the vitality of the nits is destroyed, and they soon drop off instead 
of hatching out. Of course, the whole treatment is rendered much 
more easy if the hair is cut short, and, if there are many sores, 
this is essential. Scabs and sores can be softened by fomenta- 
tions and treated with mild mercurial ointments. If sores are 
present irritating applications like Oil of Sassafras cannot be 
used at first. 

Pediculi may be found on the body and lodging in the clothes, 
but they are far more common in the head. 

Impetigo. — Impetigo is a skin affection in which there are 
numerous spots filled with matter on various parts of the body; 
the spots may run together, the discharge from them forming 
yellowish crusts and scabs. There is a contagious form of 
impetigo, which may give rise to an epidemic. A child with 
impetigo is usually in a low state of health, needing general 
tonics as well as local treatment. The scabs or crusts should be 
softened by bathing and fomenting with hot water, and, when the 
crusts have been removed, a mercurial ointment should be applied 
to the surface. If a large surface is involved, the ointment must 
be a weak one. The bowels must be regulated and the general 
condition improved. Impetigo sometimes complicates scabies and 
pediculosis, or it may follow a cut or abrasion that has got dirt 
into it and become infected, the spots then developing in the 
surrounding areas of the skin and forming patches with character- 
istic yellowish crusts and scabs. Chicken-pox gives little yellowish 
spots which are similar to small impetigo pustules, but they are 
much smaller, more uniform, and come out in crops. Any sore 
place may, by infection through scratching, become impetiginous 
in nature. 

Boils (Furuncnlosis). — These are usually due to a lowered general 
condition and an impoverished state of the blood. Medicinal 
treatment with iron, regulation of the bowels, dieting, and open- 
air exercise are necessary, and the boils themselves may have to 
be incised and fomented. In some cases boils are very persistent 
and difficult to cure. 

In large institutions trained nurses should be provided 
to do the necessary dressings and carry out the medical 
officer's instructions. They should have some know- 
ledge and experience of cases of infectious disease. 



CHAPTER X 

THE CELL, REPRODUCTION, AND HEREDITY 

Bi-Parental Reproduction. — Every human being is 
made up of millions of cells, which are of different size, 
shape, and function in different parts of the body. Also 
every human being has originally sprung from two cells, 
one coming from each parent, the male cell being 
known as the spermatozoon and the female cell as the 
ovum. These two cells unite and fuse, this marking 
the conception of what, under ordinary circumstances, 
will develop into a complete human being. The fused 
mass is endowed with the power of so developing. 

Soon after this fusion or conception, growth accom- 
panied by rapid divisions takes place. In this way 
arise enormous numbers of cells, which take on various 
shapes and forms, and are gradually evolved into the 
complete human body. 

Weismann's doctrine of the continuity of the germ- 
plasm. — It is now generally accepted by biologists that 
the germinal or germ-plasm, which contains all the cells 
which have to do with reproduction, is continuous, 
passing from one generation to another and remaining 
more or less specialised and distinct from the somatic or 
body plasm. 

Each man or woman or child is therefore but a 
temporary dwelling place for the germ-plasm, which 
passes on to originate new and successive generations. 

It is important to note, however, that each concep- 
tion introduces a new element, since fresh germ-plasm 
is added from the other parent. 
L 161 



162 THE CELL, REPRODUCTION AND HEREDITY 

We can now see that the germ-plasm is not a new 
structure developed by the body cells of an individual. 
It exists before the body cells and produces them. A 
prospective parent therefore contains the germ-plasm 
from the very first moment of his or her origin, i.e., at 
the conception by his or her parents. It is important 
to understand these points, because we have to decide 
whether the germ-plasm is susceptible to influences such 
as poisons, drugs, diseases, or deformities that have 
affected the body-plasm. 

First, it must be clearly understood that deformities 
which have affected the body cells cannot affect the 
germ-cells, so that they, in the next generation, will 
produce an individual with a similar deformity : nor 
are characters (such as immunity to disease) which have 
been acquired by the body cells impressed on the germ 
cells. 

By far the most important influences acting on a 
germ-plasm of either good or bad stock are those intro- 
duced by fusion with the germ-plasm of the other 
parent. Should this other germ-plasm be of bad stock 
and contain a taint of inherited disease, that taint con- 
taminates the good stock or intensifies the taint in an 
already bad stock. The result may or may not be 
evident in the next generation, but a good stock has 
become a tainted one or a bad stock has become worse 
in this way. 

This mixture of stocks, which may be for good as 
well as bad (for bad stocks may be raised by union 
with good stocks) is therefore the most important factor 
that influences the germ-plasm. 

As an instance of a taint contaminating a good stock, 
the Kallikak family may be quoted. Dr. Goddard has 
traced out this family (fictitiously named Kallikak) back 
through five generations to one Martin Kallikak, who 
founded both branches. In the first branch the mother 
was a feebleminded girl of unknown origin and heredity. 



HEREDITY 163 

The child born to her and Martin Kallikak was illegiti- 
mate and feebleminded. Marrying later a woman of his 
own class of good stock, Martin Kallikak founded the 
second branch in which there was no taint of mental 
defect. 

The descendants of each of these two branches have 
been traced by Dr. Goddard through five generations, 
and are nearly equal in number. The comparison is 
striking. The first branch from the feebleminded mother 
has numbered 480 in five generations. Only 46 were 
quite normal, many were wild and eccentric if not 
actually defective, and 143 were definitely mentally 
defective; 36 were illegitimate children. 

The second branch, legitimate and of good stock, has 
numbered 496 in five generations. They have all been 
normal, and many of them have been high in pro- 
fessions. 

Heredity. — Heredity is " the capacity of a plant or 
animal to reproduce individuals of a like kind." 

Departures from this rule of like begetting like are 
known as variations. They are (1) inborn and due to 
a peculiar development resulting from defect in either 
or both of the germinal cells; (2) acquired and due to 
outside influences acting after the embryo has formed : 
the latter are known as modifications. 

Inborn variations may be of several types. They may 
be either (1) progressive or forming an advance on the 
previous generation; (2) retrogressive or on the back- 
ward grade. 

Thus a person who, born of average parents, is gifted 
with some power which raises him above the average, 
is a variation of the progressive type; and a person, 
whose innate characteristics render him less able to 
compete with his fellows or to survive, is a variation of 
the retrograde type. It is natural for the human race 
to vary in this way, some on the upward grade and 
some on the downward, but there is also always a 



164 THE CELL, REPRODUCTION AND HEREDITY 

tendency to return to the average mean, and for this 
reason both progressive and retrograde variations tend 
to disappear in future generations. 

(3) Reversive, when there is a sudden reappearance 
of a character exhibited by some previous and remote 
ancestor and not by the parents. 

It is now generally accepted that the child develops 
from the germ-plasm. This is formed before the parents 
have acquired any variation, so that it is almost certain 
that no acquired variations are transmitted, and it 
follows that the nourishment and surroundings of the 
parents before conception of the offspring have no effect 
on the inherited characters handed down. 

However, some authorities suggest that the germ- 
plasms of stocks tainted with mental trouble are un- 
stable and unbalanced, so that toxic influences may 
determine a variation that would not have appeared 
under favourable conditions. 

One of the effects of civilisation is that Nurture is 
opposed to Nature. If Nature holds undisputed sway 
the unfit are not able to live, and consequently die out 
sooner or later ; but if Nurture is called in and the unfit 
are helped in every way, they are enabled to live, and 
to propagate and keep in existence a tainted stock. 

Natural selection has a great salutary effect on our 
evolution, and nowhere is its influence more effectively 
exercised than in determining inherited immunity from 
disease. If a race is subjected to a disease, those spring- 
ing from germ-plasms with a poor resisting power are 
gradually eliminated, and the race, which now springs 
chiefly from germ-plasms which have inherited a high 
resisting power, becomes more able to fight against the 
disease. 

Mutation, — It is possible for a new species to arise by 
a sudden jump from the parent species. These sudden 
jumps are known as mutations and give rise to sports, 
which are individuals with a definite new characteristic; 



MENDELISM 165 

but it must not be thought that these sports necessarily 
vary much from the parent species. Mutation is usually 
very slight though it is none the less definite, and it 
may be (1) progressive, (2) retrogressive, or (3) regres- 
sive, i.e., harking back to a previous ancestor more or 
less remote. 

Another point is that these mutations breed true if 
mated together, and, if fitted to survive, will form and 
perpetuate a new species. 

The mutation theory therefore holds that new 
varieties, i.e., individuals exhibiting new and distinct 
characters, arise suddenly and from no apparent cause. 

It might be expected that an accumulation of the 
effects of environment would tend to produce these 
sudden jumps, but though this may be the case, there 
is no weighty evidence in its favour. Indeed, the origin 
of sports is often quite independent of the environment. 
It must also be remembered that Natural Selection 
comes into play, and as a rule only those mutations 
that are suited to their environment can survive; 
further, if these mutations are to survive and not be 
swamped, it is necessary for them to arise in sufficient 
numbers to breed with one another and to have off- 
spring. 

Mendelism. — Mendelism teaches us to look on the 
germ-plasm of the animal or plant as a composite body 
made up of a great number of determinants, or con- 
trolling forces. These forces come together in an indi- 
vidual, and, instead of fusing and blending, some are 
dominant and some are latent. The individual expresses 
the dominant character, and at the same time may carry 
in his germ-plasm the latent character and hand it on 
to a later generation. Should this latent character 
meet with certain conditions in the next generation, it 
may in its turn become dominant. Should it not, it 
may finally become bred out and lost. 

Mendel also showed that, with plants, unit characters 



166 THE CELL, REPRODUCTION AND HEREDITY 

did not blend, but in succeeding generations sifted out 
into constant definite ratios. Thus, crossing a tall 
pea with a dwarf one (tallness and shortness being unit 
characters) gave a first generation of offspring " All 
tall." But the dwarf character was latent, because when 
this generation bred without further crossing, there were 
now three tails to one dwarf. The latent character was 
beginning to show itself, and it came out in a definite 
ratio. 

It can be seen, therefore, that a taint or trait may 
be latent and miss a generation, and yet be evident 
in later generations. Thus several well-known examples 
of this in the form of various deformities. 

It is not advisable here to enter more fully into the 
question of the relation of Mendelism to Mental 
Deficiency, because, although the matter has been 
widely discussed, there is no decisive evidence. It is 
exceedingly difficult to obtain reliable evidence regard- 
ing the human race, and we cannot say yet that the 
laws of Mendelism apply to the human race as they do 
to plants. 

Biometry. — Galton and Pearson formulate laws of 
Ancestral Inheritance, arguing that it is possible to 
express numerically the amount of inheritance received 
by an individual from parents, grand-parents, or great 
grand-parents. 

This method is called " Biometry," and it aims at the 
elucidation of the problems of heredity by the collection 
and skilled interpretation of large numbers of accurate 
statistics. 

The laws of Ancestral Inheritance as formulated 
should, however, be taken as applying to masses and 
not to individuals. 



CHAPTER XI 

THE CONDITION OF THE BRAIN IN FEEBLEMINDEDNESS. 

The Life-History of the Child after Conception. — 
The accompanying diagram (modified from Ballantyne) 
shows that, after conception, there are three periods : — 

(1) The period of intra-uterine or ante-natal life, 
which is sub-divided into the embryonic and the 
fcetal periods. 

(2) The natal period, when birth takes place. 

(3) The post-natal period, when the child leads a 
separate existence. 

It is necessary to point out and emphasise that con- 
ception and not birth marks the beginning of the life- 
history of the child. 

During the period of intra-uterine life the develop- 
ment and growth of the body-cells takes place; there- 
fore these cells are subject both to extraneous influences 
transmitted through the mother's blood, and to the 
innate or internal influences, which cause them to con- 
tinue to grow, and to develop. 

Two processes, development and growth, occur, and 
a certain amount of distinction must be made between 
the two, development being practically a formative 
process and growth being increase in the size of the 
miniature human being. 

The period of formation is surprisingly short com- 
pared to the period of growth. At the end of eight 
weeks from conception most of the gross formative 
processes are complete, the remaining seven months 

167 



168 THE CONDITION OF THE BRAIN 



Period during 

which inherited 

causes may 

act. 



Period during 

which acquired 

causes may 

act. 



a 
.3 


' 






£.7 
O 

Q 
o 




Germ 
Plasm 


Germ 
Plasm 






of 


of 


.2 

CD 




| Male 
Parent. 


Female 
Parent. 


*o3 

.5 
S 

O 


' o" 

Weefcr 


| 








Embryonic Life. 




8 

16 




13 

.2 

■+3 

-3 


1 Fcctal Life. 




S2 






40 






>- 




h3 




Infancy 

and 

Childhood. 











Conception. 
Development. 



Growth. 



Birth. 



Diagram I., showing the periods preceding and following conception. 
(Modified from Ballantyne). 



DEVELOPMENT AND GROWTH 169 

being the period of growth. The first period is known 
as the embryonic and the second as the foetal. 

The formative processes, which take place during the 
first weeks of intra-uterine life, are so rapid that at the 
sixth or seventh week the embryo has already taken on 
the face and form of a human being, and the different 
processes, though not perfected, have largely been 
determined by this time. 

After this week there is a slackening of development 
and an acceleration of growth. The foetus is now 
nourished by the maternal blood, which passes through 
the placenta to the foetal heart, thence going first to 
the head and brain. The fact that the blood goes first 
to the brain shows that it is necessary for that organ 
to receive better blood than the body and limbs at this 
period. 

The Brain. — We are chiefly concerned with the 
development of the brain, and, as might be expected, 
the formation of so complicated and intricate an organ 
is not completed so rapidly as the formation of the body 
and limbs. The main parts of the brain are formed 
fairly early, so that at the sixth month of intra-uterine 
life the organ has acquired its general shape but has not 
developed its fissures. At birth it is much more 
advanced but by no means completed, and for the first 
six months after birth there is very rapid growth and 
development. 

According to Tredgold the brain weighs at birth about 
300 grammes, and grows until it weighs 650 grammes 
at the end of the first six months, 750 grammes at the 
end of the first year, and about 1,200 grammes at the 
end of the fourteenth year. This increase is due to the 
development of nerve cells and their processes. The 
parts of the brain which control the association of 
impressions and ideas are the last to be developed. 
They are made up of a complex system of fibres link- 
ing up the various centres. This is important when we 



170 THE CONDITION OF THE BRAIN 

see that most of the higher intellectual faculties depend 
on the powers of association and ideation. 

The actual period when birth is taking place is a 
critical one, since the infant is exposed to considerable 
risks from accidents or injuries ; such injuries may be 
due to prolongation of birth, which throws a great 
strain on the blood-vessels of the brain and may lead 
to their rupture. However, this does not often happen, 
and gross injuries such as effusions of blood affecting 
the brain, usually cause marked physical deformities 
and paralysis, so that, if the child survives, he will be 
a mental and physical cripple belonging to one of the 
special types. (See Chapter VI). 

After birth the child may be exposed to injury and 
disease, which, by causing inflammatory mischief, may 
give rise to mental deficiency, but such cases again are 
not common. 

Pathology. — When considering pathology it must be 
pointed out that idiots, imbeciles, and the feebleminded 
all come in the same category, the difference being one 
of degree only. 

Most writers are agreed that the brains of the 
mentally deficient do not as a rule show evidence of 
gross abnormality or disease, though a certain number 
of cases may do so. Such cases are more likely to be 
reported, and thus it may be thought that they form a 
larger proportion of all cases than they really do. 

The Nerve Cells of the Brain. — The brain is made up 
of millions of nerve cells which are embedded in a 
supporting tissue, the neuroglia. From all these nerve 
cells processes or branches are sent off to communicate 
either with the nerves going to the body or else with 
other nerve cells in the brain. These communicating 
branches or fibres springing from the nerve cells pass 
from one part of the brain to the other, from one side 
to the other, and from the brain to the spinal cord, 
being, when numerous, collected into great bundles of 



NERVE CELLS 171 

fibres. Thus the brain can be regarded as having two 
systems of fibres — (1) bundles of nerve fibres coming 
down to communicate with the nerves to the body, and 
(2) an extraordinarily intricate and complete system of 
intercommunicating association fibres. 

There is no doubt that the intellectual faculties 
develop and decay with the development and decay of 
the nerve cells in the brain and their branches. Investi- 
gation of brains of lunatics shows that there is a 
degeneration of these cells leading to a decay of the 
mental powers, and the brains of idiots show, not a 
degeneration, but an under-development of these cells, 
leading to a corresponding under-development of the 
mental faculties (Bolton). 

The period of greatest growth and development of the 
brain is from its first appearance early in intra-uterine 
life to the sixth month after birth. 

We must remember, however, that the nerve cell 
needs to be endowed with the innate power to develop, 
and it is this power that is wanting in most cases of 
feeblemindedness. A cell which possesses this power 
may very occasionally be prevented from developing 
by some accident, but in by far the majority of cases 
there is wanting the innate power to complete develop- 
ment. 

In mental deficiency the brain is found to contain 
fewer cells than should normally be present, while at 
the same time these cells are imperfectly developed. 
Bolton states that there is no adequate supply. Im- 
perfect development of these nerve cells means that 
they do not send out the processes and interlinking 
fibres that are all-important for transmitting impulses, 
for correlating the various senses, and for association, 
reasoning, and ideation. There is also an irregular 
arrangement of the cells, which may be at all angles 
or upside down. They are also often pigmented. Areas 
of sclerosis with over-growth of the supporting connec- 



172 THE CONDITION OF THE BRAIN 

tive tissue may be often present also. Sherlock in rela- 
tion to this states that two conditions may be present; 
first, there may never have been an adequate supply, 
and second, that there may have been loss of nerve 
cells. When gaps in the supply of nerve cells are 
present it looks as if loss has taken place. Further, 
Dr. Tredgold, to whose careful researches on this sub- 
ject we are much indebted, finds that the proportion 
of immature cells seems to be distinctly in relation to 
the degree of mental defect. 

The human brain can be compared to a well-organised 
modern community, where overhead there are innumer- 
able telephone and telegraph wires interlinking and 
co-ordinating the activities of the great centres, which 
in their turn have channels of communication with the 
forces they control. Just as a primitive state, in which 
there has been little development of communication 
between the various centres of activity, is slow to 
respond to any call made upon it and falls behind other 
better organised communities, so the brain of a feeble- 
minded child is not well enough endowed to allow of 
efficient self-government. 

Again, just as some primitive communities may be 
comparatively well advanced in some branches and 
backward in others, so under-development of the mental 
powers, besides being more or less general, is in many 
cases of an uneven or irregular nature, some children 
being especially deficient in one mental process and 
others in another. 

However, this comparison between the feebleminded 
child and the imperfectly governed community must 
not be carried too far, for the two differ in that the 
community could by effort and application reach the 
level of other communities, while the feebleminded child 
can only be improved to a limited extent, and can 
never reach the level of a normal child. 

Meningitis and Encephalitis. — Meningitis is an inflam- 



MENINGITIS AND ENCEPHALITIS 173 

mation of the membranes surrounding the brain, and 
encephalitis is inflammation of the brain substance. 
A combination of the two may occur or a previous 
inflammation may leave scar tissue which is liable to 
contract and cause deformity. Meningitis and inflam- 
matory processes can cause an arrest of development, 
the arrest in this case being not inborn but accidental 
or acquired. 

Comparatively speaking, feeblemindedness is not often 
due to meningitis or encephalitis, and cases caused by 
such lesions come under the heading of secondary mental 
deficiency. Some observers consider that these inflam- 
matory lesions play a large part in the causation of 
feeblemindedness ; but it must not be forgotten that, 
not only may meningitis occur around the brain of a 
child already feebleminded, but that the brain of such 
a child is more liable to inflammatory and degenerative 
conditions than is that of a normal child. 

Both Wilmarth and Wilhete found that evidences of 
a slow meningitis were not uncommon in the brains of 
mentally deficient children, but this does not prove that 
it is not usually a secondary condition rather than the 
cause of the mental trouble. 

Wilhete found that a slow progressive meningitis was 
more common in the feebleminded children suffering 
from fits, and this coincides with clinical observation, 
for a certain number of cases do not improve with treat- 
ment but become steadily worse both as regards the 
number and severity of the fits and the mental capacity ; 
others, who react to treatment, improve in every way. 
Gross abnormalities of the brain, such as porencephaly 
and hemiatrophy, are more common in the brains of the 
mentally defective, especially in those of the lowest 
grades, but they are comparatively speaking unusual. 

We can conclude from recorded facts that : — 

(1) In the majority (90 per cent.) of cases of mental 
deficiency there is a permanent under-development 



174 THE CONDITION OF THE BRAIN 

and numerical insufficiency of the essential part of the 
brain tissue, viz., the nerve cells and their branches; 
and that this under-development is not due to disease 
or injury, but to an innate want of power to develop. 

(2) In the minority of cases (10 per cent.) the power 
to develop was originally present, but disease or injury 
either affected the brain so as to prevent normal develop- 
ment or destroyed parts essential to proper mental 
activity. 

Development, Reproduction, and Heredity in Rela- 
tion to Pathology . — Let us now see how these facts of 
pathology adjust themselves to the theories of heredity 
and to our knowledge of development and reproduction. 

It has been pointed out that the germ-plasm is con- 
tinuous, that it has a fresh element introduced by 
bi-parental reproduction, and that it is subject to varia- 
tions, progressive or regressive, to reversion and to 
mutation. It has been shown also that there are rapid 
formative processes in the period of intra-uterine life 
making it quite possible that, if the hereditary powers 
of development are impaired, those processes may re- 
main incompleted. 

Primary mental deficiency arises from this failure of 
development, which is due to causes inherent in the 
germ-plasm, whereby that substance is not able to re- 
produce in full the highly developed brain of the normal 
human being, and it is a variation of the retrograde 
type. 

The several reasons for this opinion are based on 
pathological and other grounds, and are as follows : — 

(1) We have already seen that pathological evidence 
shows definitely that there is an incomplete develop- 
ment of parts of the brains of the mentally deficient, 
the nerve cells being fewer in number and imperfectly 
formed. Thus the mentally deficient do not show new 
or mutational characters, but general incompleteness of 
development. 



NATURE OF FEEBLEMINDEDNESS 175 

(2) The children born to two parents, who are both 
mentally deficient, are not always similarly affected and 
may be of normal intelligence. I know that this is 
contrary to the generally accepted opinion, and that 
there is not much evidence to support this contention. 
There is no doubt that almost all of the children born 
under such circumstances are mentally deficient. How- 
ever, Richardson quotes an example where a child of 
normal mental powers was born to two parents, who 
were both mentally deficient, the father being a feeble- 
minded boy of eighteen and the mother a feebleminded 
girl of sixteen. It seems, therefore, that even when 
both parents are feebleminded the children will not 
necessarily be feebleminded, though the tendency for 
them to be so is very strong indeed. In my opinion 
mental deficiency is a variation and not a mutation; if 
it were a mutation all the children born to parents who 
were both mentally deficient would be similarly affected. 
There is also to be borne in mind the law of heredity, 
which states that there is always a tendency to return 
to an average mean. 

(3) About the same time as important developments 
take place in the brain there are important formative 
processes going on in structures which, as we have seen, 
are often imperfect in the feebleminded. Such structures 
are the external ear, the palate, the fingers, the eyelids, 
and other deformities which constitute the stigmata of 
degeneration. Ballantyne states that the chief forma- 
tive processes of these structures and those of the brain 
are completed at about the same time of intra-uterine 
life. This certainly suggests that there is an incomplete 
development in the brain as there is in these other parts. 

It must be pointed out here that the deficient develop- 
ment of the brain cells may not be evident microscopi- 
cally till later, but the number of the brain cells is 
determined, and they are originated and have received 
their endowment of power to develop much earlier on. 



176 THE CONDITION OF THE BRAIN 

(4) Feeblemindedness is not likely to be a reversion to 
a previous type. It has already been pointed out that, 
as far as concerns a discussion on heredity and the 
causation of feeblemindedness, we can put the idiot and 
the feebleminded in the same category, the difference 
being only one of degree. 

Now an idiot is far less sensible than the lowest type 
of the native races or even of the lower animals, for he 
cannot guard himself against common physical dangers : 
an aboriginal or low type, if brought to Europe at a 
very early age, would develop far greater intelligence 
than the best of idiots or imbeciles, though there is little 
doubt that he would not approach the European 
standard; further, there are mentally deficient animals 
just as there are mentally deficient human beings, but 
Natural Selection exerts its influence and such animals 
die out. 

It might seem that some of the more definite types 
such as Mongols or Microcephalics are sports or muta- 
tions, and would breed true to their type; but this is 
probably not the case, because the brains show an 
incompleteness of development rather than any new 
morphological characters. Microcephaly may be a 
reversion to an ancestral type of small brain, but it is 
a curious fact that this deformity sometimes affects more 
than one of the children of a family and may affect 
them all. 

(5) If mental deficiency were not due to this loss of 
the innate power to develop, but were due to inflamma- 
tory conditions such as meningitis, acting during 
embryonic and foetal life and determining an arrest of 
development, it should be more common where disease 
and bad conditions prevail. But the available evidence 
points rather to the reverse as being the true state of 
affairs. 

Mogridge states that the ratio of the feebleminded to 
the general population is the same in all the States of 



CONCLUSIONS 177 

the Union, and there is very little difference between the 
ratio in the United States of America and that of older 
countries. 

When Norway and England were used as illustrations 
it was thought that alcoholism was responsible for a 
large amount of the existing feeblemindedness; but in 
Iowa, where the drink habit is as low as it can be, there 
is the same proportion of feeblemindedness as in the 
other States. 

Nor does pathological evidence show that inflamma- 
tory mischief often gives rise to mental deficiency by 
causing arrested development; it may supervene later, 
but in such cases does not occur until after the incom- 
plete development has been determined. 

Conclusions. — (1) It seems therefore that feeble- 
mindedness, with the exception of certain types due to 
definite lesions, is caused by a failure in the process of 
development, resulting in numerical insufficiency and 
imperfect formation of the nerve cells and their branches 
in the brain. 

(2) That the incomplete development is due to the 
inability of the germ-plasm to endow the cells, which 
are to make up the highly specialised human brain, 
with power to produce either (1) a sufficient number, or 
(2) a sufficiently high type of nerve cells to complete 
the formation of a normal organ. Feeblemindedness 
is, therefore, a variation of the backward or retrograde 
type. 

(3) That this incomplete development is lifelong, and 
is chiefly evident in that the imperfect condition of the 
nerve cells results in an insufficiency of the association 
fibres which serve to join up and correlate the various 
parts of the brain, mental deficiency following as a 
natural result. 

(4) The types described as exceptional in conclusion 
(1) form a small minority of all cases, and are secondary 
or accidental types due to injury or disease. 

M 



CHAPTER XII 

THE CAUSATION OF FEEBLEMINDEDNESS 
INHERITED FACTORS 

The causes of mental deficiency can be divided into two 
classes : — 

(1) The inherited causes affecting the parental germ- 
plasm before conception of the child. 

(2) The acquired causes, i.e., factors that may affect 
the embryo or foetus in utero, or the child after 
birth. 

So much confusion has arisen owing to misunder- 
standings as to what are inherited and what are acquired 
conditions, that it is of advantage to explain here 
exactly what is meant by these terms. 

A reference to Diagram I., p. 168, will show (1) that 
inherited causes must act before conception, and (2) 
that acquired factors may affect the embryo or foetus 
in utero or the child during or after birth. It is im- 
portant to appreciate that conception and not birth 
marks the beginning of life for the child, and that, 
though for the first nine months the child does not live 
an independent existence, it has nevertheless started 
on its career as a human being, has inherited its innate 
characteristics for good or for ill, and is for many of these 
months practically a fully formed human being. There- 
fore, when we divide the causes of mental deficiency into 
two classes, the inherited and the acquired, by the 
inherited causes we mean those affecting the parental 

178 



INHERITED FACTORS 



179 



germ-plasm before conception of the child, and by the 
acquired those affecting the embryo, the foetus, or the 
child. Acquired factors acting on the child through 
their effect on the mother during the gestation period 
of intra-uterine life are none the less acquired, and are 
not inherited in any way. 

In Chapter I. cases of feeblemindedness were divided 
into two classes : — 

(1) Primary, forming 90 per cent, of all cases. 

(2) Secondary, forming 10 per cent, of all cases. 
Though the causes of feeblemindedness are by no 

means clearly denned, it seems probable that class (1), 
the Primary form, is caused by what is called the 
Neuropathic Inheritance, with or without one or more 
of certain reinforcing factors, which are either inherited 
or acquired; and that class (2), the Secondary form, 
is caused by disease, inflammation, or injury. 

We can now proceed to tabulate and discuss the 
causative factors under their several headings. 

Inherited Factors. — The Inherited Factors are best 
tabulated as follows : — 



Inherited factors 
affecting the 
parental germ- 
plasm before 
conception of 
the child. 



(a) Transmitted 
neuropathic 
taint, giving 
neuropathic 
inheritance. 



(b) Vitiating 
disease or habits. 



(c) Sociological 
factors. 



Mental deficiency. 

Insanity. 

Epilepsy. 

(Hysteria and 

Neurosis.) 

Alcoholism. 
Tuberculosis. 
Other debilitating 
disease. 



Ages of parents. 
Blood- 
relationship or 
Consanguinity 
of parents. 



(a) Neuropathic Inheritance. — There is no doubt 



180 INHERITED FACTORS 

whatever that by far the most important cause of feeble- 
mindedness is an inherited taint of certain affections of 
the nervous system, such an inheritance being described 
as the Neuropathic Inheritance. These affections of the 
nervous system, which have such a far-reaching effect, 
are mental deficiency, insanity, and epilepsy. They 
seem to be quite interchangeable as far as heredity is 
concerned, though the descendants of persons afflicted 
with each disease are more likely to suffer from the same 
trouble : this is especially the case with epilepsy, 
Gowers finding that 50 per cent, of the descendants of 
epileptics were similarly affected. 

A family history of insanity, epilepsy, or mental 
deficiency occurred in 48.4 per cent, of 1,000 Man- 
chester cases of feebleminded children,* and, if it had 
been possible to obtain all details, this percentage would 
probably have been increased, since Tredgold, after 
making a more searching enquiry into a smaller number 
of cases, found a neuropathic inheritance of epilepsy or 
insanity in 64 per cent. We have already seen that the 
Royal Commissioners for the Care and Control of the 
Feebleminded (1908), after hearing a large amount of 
expert evidence, summed up conclusively in favour of 
the inherited nature of feeblemindedness. 

A history of neurosis or hysteria or other manifesta- 
tions, pointing to an unstable nervous system in either 

*A study of the family histories of 1,000 cases of feebleminded- 
ness seen in Manchester gives us the following general conclu- 
sions : 48.4 per cent, showed a family history of insanity, epilepsy, 
or mental deficiency, the three inherited causes of neuropathic 
inheritance. In 6.8 per cent, of these there was a combination 
of the two or three factors. 

Including alcohol and tuberculosis, 69 per cent, showed a history 
of one or more of the causes classed as inherited. 

As we shall see, these figures are not of any great value, 
especially as regards indefinite conditions like tuberculosis and 
alcoholism, where only the most complete family histories are of 
real value. The family histories Avere very carefully taken, but 
the unwillingness and ignorance of parents giving the information 
made them incomplete and inexact in many instances. 



ORDER OF BIRTH OF PARENTS 181 

of the parents, may show that the child comes from a 
bad stock ; but such conditions as neurosis and hysteria 
are very indefinite, and include a large variety of 
symptoms that may be due to several causes other than 
an innate weakness of the nervous system. 

The neuropathic inheritance is enough in itself to 
determine feeblemindedness, but it may be reinforced 
by some additional factor; additional factors such as 
disease or poisons will be discussed later, but of more 
importance is an hereditary taint on both sides of the 
family, the one taint reinforcing the other. 

Therefore the neuropathic inheritance, whether it is 
reinforced or not, is by far the most important cause of 
primary mental deficiency. 

Unless this fundamental fact is fully appreciated and 
widely known little can be done to reduce the numbers 
of the feebleminded. The recommendations of the 
Royal Commissioners, the efforts of the American States, 
and the work of all the best societies are based upon 
the fact that feeblemindedness is inherited and inbred, 
or, as the Commissioners put it, " spontaneous " and 
not necessarily developed as a result of the bad influ- 
ences of environment or disease. 

Order of Birth of Parents. — The late Dr. Hunter, of 
the Royal Albert Institution, showed me the results of 
his enquiries into the pedigrees of families containing 
mentally deficient persons, and he proved that mentally 
deficient children are found much more commonly in 
the families of those who are the first-born of the 
earliest-born members of the branch that is affected by 
the hereditary taint : the first-born are more likely to 
have mentally deficient children and next to them the 
second-born, and so on, there being a more or less 
steady diminution in the tendency to transmit the taint 
as the parent comes later and later in his or her family. 
Thus it seems that if there is an hereditary taint in a 
family, the first-born are the most likely to transmit 



182 INHERITED FACTORS 

that taint, though not necessarily to show it themselves. 
To be of any value in illustrating this point the family 
history should go back beyond the parents and also 
include the father's and mother's places in their respec- 
tive families. Further investigations are needed to 
establish these results as facts, but they are very 
striking. 

(b) Vitiating Disease or Habits. 

Alcoholism, — Much has been written on the effect of 
alcoholism of the parents as a cause of mental deficiency. 
One of the most valuable and recent accounts will be 
found in the British Journal of Inebriety, January, 1909. 

Most of those who support the view that alcoholism 
has a great effect in causing mental feeblemindedness 
base their conclusions on statistics. Now statistics con- 
cerning alcoholism are, as a rule, utterly worthless for 
two reasons : (1) because many people are not clear as 
to what is meant by alcoholism; and (2) because only 
personal and intimate knowledge of the habits of both 
parents is of any real value for statistical evidence, here- 
say evidence being open to many objections. 

Therefore let us first understand clearly what is meant 
by alcoholism, and then let us see how alcohol can 
possibly act. 

The Royal Commission find that 60 per cent, of 
chronic inebriates are either mentally deficient, or are 
persons of such unstable mental balance that they are 
subject to violent outbreaks from small doses of alcohol. 
These are the individuals classed as chronic inebriates, 
who send up our records of drunkenness. In reality, 
like moral defectives, they are the unfortunate inheritors 
of mental instability, and if they are the progenitors 
of mentally deficient children, it is because they come 
from an afflicted stock and not because they have 
poisoned themselves with alcohol. Their tendency to 



ALCOHOLISM 183 

alcoholism is simply evidence of the neuropathic inheri- 
tance. On the other hand, there are many quiet 
drinkers who continuously poison their systems with 
alcohol but are not known to their relations as 
drunkards. 

These points show how difficult it is to obtain definite 
and reliable evidence on this problem, and it is only to 
be expected therefore that statistics will vary very 
much. The following figures are given to illustrate the 
uselessness of drawing conclusions from any but the 
most accurate and complete family histories. 

Barr found a family history of alcoholism in 4.4 per 
cent., Beach and Shuttleworth in 16.4 per cent., Bourne- 
ville in 62 per cent., and Tredgold in 46.5 per cent. 
The last author points out that, in five-sixths of these 
family histories showing alcoholism, there was also a 
neuropathic heredity. The Manchester cases showed 
9 per cent. Much the same result is obtained in com- 
paring the statistics concerning a family history of 
tuberculosis. Tuberculosis is so common and so varied 
that family histories given by any persons other than 
medical men are usually misleading. 

Memoir X. of the Eugenics Laboratory (Pearson and 
Elderton) illustrates these points more fully, and a 
careful analysis of the family histories shows how slight 
may be the effect of parental alcoholism on the children. 

According to the views of many eminent neurologists, 
alcohol has a much greater poisoning effect on a stock 
already tainted with a neuropathic inheritance than on 
an untainted stock. If this is true, it is more likely 
that parental alcoholism may have a definite action 
purely as an accessory or determining cause. We have 
no proof of this beyond the fact that neuropaths are 
certainly very much more susceptible to alcohol than 
are persons of sound nervous system. Mott comments 
on the rarity of alcoholic cirrhotic disease of the liver 
in asylums, a fact which points to the rarity with which 



184 INHERITED FACTORS 

mental degenerates take enough alcohol to poison their 
tissues. More often they are subject to violent out- 
breaks from taking small quantities, followed by forced 
or voluntary periods of abstention with freedom from 
its toxic effects. It is possible, therefore, but by no 
means proved, that alcohol has a selective action on 
the nervous tissues of neuropaths. 

The effect of alcoholism in the mother during preg- 
nancy and after conception is not an inherited factor, 
and is discussed later under acquired causes. 

Tuberculosis. — Much of what has been said concern- 
ing the family histories of alcoholism applies also to 
those of tuberculosis. As in the case of alcoholism, little 
reliance can be placed on statistics, for (though I am 
convinced that tuberculosis is commoner in the families 
of the mentally deficient than in those of normal per- 
sons) it is very difficult to obtain reliable histories. It 
is well known that the insane are especially liable to 
suffer from tuberculosis, this tendency being due to a 
weak resisting power to infection and to the effects of 
the disease. We have not noticed that the children at 
Sandlebridge are especially liable to tuberculosis, but 
their lives are lived under conditions especially unfavour- 
able to the development of this disease. Tredgold states 
that, in conjunction with nervous abnormality, these 
two factors, alcoholism and tuberculosis, have a great 
importance in the causation of idiocy, imbecility, and 
many other morbid conditions of the nervous system. 

My conclusions concerning tuberculosis as an inherited 
factor are similar to those regarding alcoholism, though 
I am inclined to the opinion that tuberculosis is more 
likely to have an effect than is alcoholism. 

Syphilis. — It is almost impossible to find reliable statis- 
tics of the effect of syphilis acting as an ante-conceptional 
cause in the production of mental deficiency. Most of 
the authorities on the subject say that it has very little 
effect, and certainly as far as statistics go this seems 



SYPHILIS 185 

to be the case. Statistics as regards syphilis are 
generally quite useless, because few parents will admit 
that they have had the disease. 

We know a great deal about syphilis as a disease and 
as a disease that may pass from mother to the child in 
utero, but this is not true inheritance, and we know 
very little that is definite about the effect of syphilis 
on the inheritance handed down. 

As a disease syphilis produces great anaemia and 
debility, and often has a selective action on the nervous 
tissues, but we have no evidence to prove that it has 
any action on the germ-plasm. Syphilis often produces 
death or disease of the foetus, and a child born appar- 
ently quite well may develop the disease; but this is 
not evidence that the germ-plasm is affected. Children 
born later to the same parents are less likely to be 
affected, and the fact that they can be quite well- 
developed when born shows that the innate power to 
develop is not impaired. The fact that evidences of the 
disease may only appear some time after birth has 
nothing to do with inheritance, because the infection is 
present all the time even though it does not show itself 
at once. 

Dean found that a large proportion of idiots show 
the Wasserman serum reaction, and Gordon found that 
of 400 congenital mental defectives 66 or 16.5 per cent, 
gave a reaction. (Five years and under, 26.5 per cent. ; 
6-10 years, 15.0 per cent; 11-20 years, 17.6 per cent.) 
This reaction is held to be limited to cases with syphilitic 
infection. There is, up to the present, however, no 
proof that congenital syphilis can poison or deform the 
germ-plasm so that the inheritance is altered and the 
third generation affected. 

As we said before, much has been written of alcohol, 
tubercle, and syphilis as causes of feeblemindedness, but 
it has never yet been shown that districts or countries, 
where these factors are more prevalent or increasing, 



186 INHERITED FACTORS 

have a larger or increasing proportion of feebleminded 
persons; nor, as Ireland points out, has it been shown 
that more feebleminded children are born at periods of 
the year nine months after the times when drunkenness 
is common (such as the New Year in Scotland). 

Further, in countries where there has been a decrease 
in factors like alcoholism there has been no correspond- 
ing decrease in mental deficiency. But since there is 
no standard system of registering mental defect, the 
proportion registered depends largely on the number of 
institutions or organizations in any one district or 
country. The numbers tend to increase with the regis- 
tration of school cases, so that nobody can prove at 
present that the proportion of feebleminded to the 
population is increasing or decreasing. 

These arguments point to the fact that statistical evi- 
dence of the effect of vitiating disease or habits in the 
parents as an inherited cause of feeblemindedness is 
quite inconclusive and unreliable, but the effect of the 
neuropathic inheritance as the real cause of feeble- 
mindedness of the primary type is probably great. 

Evidence based on individual cases is, if anything, still 
more convincing. It is easy to quote scores of instances 
where a feebleminded woman or man has handed down 
the trait so that it has persisted through generation after 
generation. Examples such as that shown in Diagram II. 

DIAGRAM II.— Showing the Inherited Nature oe Feeblemindedness. 

Male married Female 
(Died in | (Paralysis) 

Asylum) 

i i j i 

Son married Son married Son married Daughter 

(Mental Defective) I (Died in Asylum) (Died in Asylum) 

Daughter married Daughter 

(Died in Asylum) (Mental Defective) 



I I I I I 

Child Child Daughter Son Daughter 

(Mental Defective) (Mental Defective) (All three Mentally Defective, 

and two at Sandlebridge) 



CONSANGUINITY 187 

are common, and the Kallikak family quoted on p. 162 
is another instance. 

It is only right to give great importance to the statisti- 
cal side of the evidence, but surely the evidence of these 
and other numberless cases, where feeblemindedness can 
be traced like a black stain from one ancestor through 
many generations, counts for a great deal. However, 
it does not greatly matter which of the two kinds of 
evidence we consider to be the more important, for both 
lead strongly to the conclusion that primary feeble- 
mindedness is always inherited, and that the acquired 
conditions, if they have any effect at all, act merely as 
secondary factors. 

At the same time these conclusions agree with the 
accepted theories of heredity, and do not rest on the 
supposition that acquired characters can be inherited; 
many of the arguments advanced periodically as 
to the causation of feeblemindedness do rest on such a 
supposition. 

(c) Sociological Factors. Consanguinity. — Con- 
sanguinity is one of the traditional causes of feeble- 
mindedness, and there is much to be said against the 
marriage of blood relations. Such inter-marriages 
certainly increase the likelihood of the appearance of any 
undesirable traits which may exist in the family. As 
Sanem says, " La consanguinite eleve l'heredite a sa 
plus haute puissance." In spite of this such marriages 
are not a common cause of feeblemindedness, simply 
because they are not very common and also because 
there is not always an undesirable trait to be intensified. 

Ages of Parents. — The ages of the parents may have 
some effect. In the Mongolian form of mental deficiency 
there is strong evidence to show that there is an exhaus- 
tion of the reproductive powers of the mother. Mongols, 
however, do not form a large proportion of the feeble- 
minded. Possibly after the usual child-bearing period 
there is a greater liability with increasing age to bear 



188 INHERITED FACTORS 

defective children, but only because there is an inborn 
taint which has more chance of coming to the surface 
when the reproductive powers are weakened. Dissimi- 
larity in the ages of the parents has very little effect, 
and it is not found more often in families containing 
feebleminded children. 

Illegitimacy. — There is little doubt that a greater pro- 
portion of illegitimate children are feebleminded, but 
this is not due to the fact that they are illegitimate. It 
is because the mother is often feebleminded, and for 
that reason has been the more easily led astray. 

In the same way a history of a tendency to suicide 
simply means that there is a tendency to unstable mental 
balance in the family. 

Cancer. — There is no evidence to show that cancer is 
a cause of mental defect, and it is only mentioned 
because fallacious statements as to its effects are some- 
times made. Cancer could only act as a poisoning and 
weakening agent, and we have already seen that such 
conditions have little effect on the germ-plasm. More- 
over, cancer occurs late in life after the children have 
been born. In 3.8 per cent, of my cases there was a 
history of cancer, a proportion that is no larger than 
would be found in any list of family histories. 

Conclusions as to Inherited Factors. — (1) A family 
taint of mental deficiency, insanity, or epilepsy, consti- 
tuting what is known as the Neuropathic Inheritance, is 
the underlying cause of primary feeblemindedness (90 
per cent, of all cases). 

(2) Other factors, such as ante-conceptional parental 
alcoholism and tuberculosis, may have some effect as 
accessory factors in the production of feeblemindedness 
if they are present in conjunction with the Neuropathic 
Inheritance ; but there is no conclusive evidence to show 
that this is the case, and, acting by themselves, they 
probably cannot have much effect in the causation of the 
primary type of feeblemindedness. 



CHAPTER XIII 



CAUSATION OF FEEBLEMINDEDNESS. 
ACQUIRED FACTORS 



Acquired factors may affect the foetus in utero and the 
child during or after birth. 

They can be tabulated as follows : — 



Ante 
natal 
acting ■{ 
before 
birth. 



Abnormal conditions 
of:— 



(a) 



Mother during 
pregnancy. 



2. Foetus. 



(c) 



shock and 
Injury. 



Mental 
stress, 
(o) Physical 
Disease : — 
Alcoholism. 
Tubercle. 
Syphilis. 
■(d) Age. 
/ Injury, disease, especi- 
\ ally of the brain. 




Post 
natal 

acting - 

after 

birth 



Abnormalities of labour such as prolongation 
with resulting congestion of brain or 
extravasation of blood. 

Convulsions or injury at birth. 

Cretinism or deficiency of the thyroid 

gland. 

Epilepsy and convulsions. 

Sense-deprivation. 

Injury. 

Infectious fevers. 

Meningitis. 



1 7. 



Brain disease. 

Mental shock. 
189 



Encephalitis. 

Syphilis. 

Tumour or abscess. 

Sunstroke. 



190 ACQUIRED FACTORS 

Ante-Natal. 

(1) Abnormal conditions of the mother during 
pregnancy, 

(a) Mental Shock and Stress. — In about 10 per cent, 
of cases there is a history of abnormal mental conditions 
of the mother during pregnancy. It is not uncommon 
for a mother to attribute the mental trouble in her child 
to some shock or fright she herself has sustained during 
pregnancy, but there is little doubt that such shocks in 
themselves have only a small effect on the fcetus, and 
in any case the liability to these shocks often points to 
an unstable nervous system in the mother. Ballantyne 
discusses the literature of this subject, and comes to the 
conclusion that mental impressions have little effect on 
the fcetus. Very often such mental shocks gain an 
exaggerated importance each time the mother repeats 
her tale. Again, many of the shocks are sustained late 
in pregnancy long after the fcetus has been formed, a 
point which should be thought of when mental impres- 
sions are said to have caused physical deformities 
resembling in nature the origin of the fright. Continued 
anxiety and mental stress act on the mother as a debili- 
tating factor. 

(b) Physical Injury. — Physical complications are 
much more likely to have an effect. A fall or injury to 
the mother may well injure the fcetus. Peterson found 
in some children post-mortem signs of an eld brain 
lesion, which must have caused death had it occurred 
while the child was leading a separate existence. But 
these cases, if mentally affected, generally show the 
result of their injury in physical disabilities and form the 
cerebral diplegic type of feebleminded children. 

(c) Disease. — Any of the general constitutional 
diseases or other debilitating conditions attacking the 
mother may have a toxic effect on the embryo or foetus 
if it presents anv weak points to their attack and if the 



ALCOHOL 191 

attack comes early in intra-uterine life. In this connec- 
tion an inherited instability of the nervous system in the 
embryo might possibly be a weak point offering a poor 
resistance to any toxin, especially if that toxin had a 
selective action on the nervous system.* But practi- 
cally it is very doubtful whether these abnormal con- 
ditions of the mother during pregnancy have any effect 
at all on the development of the brain of the embryo 
even when this inherited instability is present. A 
history of such disease is quite common in the mothers 
of sound and healthy children, and alcoholism and 
tuberculosis are examples of these constitutional debili- 
tating conditions, but feeblemindedness is cot more 
common where these are worst. In discussing the effect 
of alcoholism during pregnancy there is much to be said 
on either side, and a full account can be found in the 
British Journal of Inebriety, 19th January, 1909. Dr. 
Potts, in that discussion, attaches much importance to 
maternal drinking during pregnancy as a potent influ- 
ence in the causation of mental degeneracy. 

But on the other hand statistics can be found showing 
that there is no relation between mental and physical 
weakness in the children and drinking in the mother. 
(Mem. X. Eugenics Laboratory.) 

Experimental evidence shows that alcohol is a poison 
to the tissues, but that does not prove that it can pass 
from mother to foetus and arrest development; and, 
often, the very fact that the mother drinks is evidence 
that she comes from a neuropathic stock. 

The only decision to which we can come is that there 
is no conclusive evidence on either side, and we can but 
infer that alcohol as a cause of feeblemindedness acting 
(1) on a foetus untainted with neuropathic heredity, 
probably has no effect in altering or arresting develop- 
ment, but acting (2) on a foetus already so tainted and 
possessing a weakened nervous system, its toxic 
* See discussion, p. 185. 



192 ACQUIRED FACTORS 

influences may possibly have a determining and secon- 
dary effect. 

Active tuberculosis in the mother during pregnancy 
does not mean that the child will be weakened physi- 
cally, since children born under such conditions are 
often quite well-nourished and, if effectively protected 
from infection, develop normally. Evidence points to 
the fact that the tubercle bacillus only passes from the 
mother to the foetus in very exceptional instances indeed. 
We have already seen that mental degenerates show a 
weak resisting power to tuberculosis, and we conclude 
that, with tuberculosis as with alcoholism, there is little 
reliable evidence to show that either acting on the 
mother during pregnancy can determine feebleminded- 
ness in the child. 

(d) Age. — The age of the mother may have some 
effect but many deficient children are born early in the 
family. Mongolian imbeciles are often the last children 
of a large family, and it has been suggested that this 
condition is the result of a wearing out of the reproduc- 
tive powers of the mother by repeated pregnancies. 

(2) Injury and disease of the foetus. — Injury and 
disease of the foetus during intra-uterine life are not 
common causes of feeblemindedness. We have pre- 
viously described how sometimes the foetus may sustain 
an injury to the brain which would have caused death 
if the child had been living a separate existence, and 
how such injuries may cause the type of mental 
deficiency known as cerebral diplegia; but these cases 
are comparatively rare. 

Natal Causes. — Factors acting at birth such as pro- 
longation of labour, protracted pressure, asphyxia 
neonatorum, and injury have little effect in the causa- 
tion of the ordinary or primary type of feebleminded- 
ness. They may cause a comparatively gross lesion of 
the brain and some accompanying physical deformity, 
but such cases belong to the secondary form and consti- 



POST-NATAL 193 

tute a special type. Difficulties at birth may or may 
not be noted in taking the history, but they are not 
more common in the histories of feebleminded children 
than in those of ordinary children, and they are often 
given an exaggerated importance by parents anxious to 
explain the mental state of their child. 

Prematurity may give a greater liability to physical 
weakness, but it is not necessarily a handicap to mental 
development. 

Post-Natal. 

(1) Cretinism, — Cretinism, due to deficiency or loss of 
the effect of the secretion of the thyroid gland, is one 
of the special types of mental deficiency, and has already 
been discussed in Chapter VI. 

(2) Epilepsy and Convulsions. — Apart from epilepsy, 
infantile convulsions are common in the feebleminded. 

Convulsions are paroxysmal attacks characterised by 
irregular and purposeless contractions of the muscles, 
and are usually accompanied by unconsciousness. Since 
attacks of abdominal or other pain may be mistaken for 
slight convulsions, and since convulsions are often a 
terminal event in fatal diseases, it is not always easy 
to obtain a reliable history from the parent. Quite a 
number of mothers regard convulsions in infancy as 
inevitable or at least of no importance, but severe ones 
are, as shown below, really rare in infants of good 
family history. Mcllraith regards them as uncommon 
unless there is a hereditary disposition. Ashby, referring 
to the causation of convulsions, said : " The hereditary 
disposition to convulsions is probably the most im- 
portant factor." 

Severe infantile convulsions are more common in the 
families of persons tainted with feeblemindedness, but 
they are the result rather than the cause of the brain 
condition. 

If an epileptic child is feebleminded (or if a feeble- 

N 



194 ACQUIRED FACTORS 

minded child is epileptic) the two conditions are not 
in the relation of cause and effect but are both congeni- 
tal, with the exception of those cases in which the fits 
are due to meningitis and are not truly epileptic. 

(3) Sense- deprivation, — Sense-deprivation may be the 
cause of considerable dulness or of slow development, 
since some of the avenues for the passage of sense- 
impressions to the brain are cut off. However, it has 
been abundantly proved that it needs more than the 
greatest degree of blindness or deafness to produce 
mental deficiency if proper education can be provided, 
and the wonderful achievements of Miss Helen Keller 
are amongst the strongest evidence in support of this. 
Of course absolute deprivation of all the senses would 
leave no avenues to the brain, but the point to be 
appreciated is that neither deafness nor short-sight of 
any degree causes real mental deficiency. 

(4) Injury. — Too much importance must not be given 
to a history of injury because parents, when trying to 
explain the mental condition of their child, usually 
discover and exaggerate some fall or blow which they 
consider to have been the starting point of all the 
trouble. 

Again, a fall may be caused by the first epileptic fit 
and yet the history given is that of a fall followed by 
fits. If the fall or blow is followed by unconsciousness 
for some time with a temporary or permanent paralysis, 
it may be more important, but such cases are very un- 
common, and the history should be examined for 
hereditary taints. 

(5) Infectious Fevers. An infectious fever does not 
cause ordinary feeblemindedness, and when the mental 
condition has definitely followed a condition like measles 
or scarlet fever, as in the case quoted below, it is due 
to inflammatory processes acting on the brain. In 
many cases there was mental deficiency before the attack 
of fever, which had attained an exaggerated importance 



CONCLUSION 195 

in the mind of the parent. An infectious fever may 
cause sense-deprivation, but this has been discussed 
above. 

W. F., age 5 years; family history negative; child is mentally 
deficient, and the condition is said to have followed an attack of 
measles at the age of 3£ years, the child being normal before 
the illness. 

(6) Brain Disease. — Encephalitis and meningitis, 
which are inflammatory and destructive processes in the 
brain or its protecting membranes respectively, may 
give rise to permanent mental deficiency, but such cases 
usually show evidences of physical disease in addition. 
The pressure of the fluid in hydrocephalus or contrac- 
tion of scar-tissue in the brain may affect the sensory 
centres. 

Congenital syphilis acting on the child may produce 
degenerative processes in the brain, but such cases are 
rare, and generally the disease can be more or less cured 
by treatment, so that there is little mental dulling. 

Sunstroke was said to be the cause of the mental 
trouble in one of my cases, but it is a very rare condition 
in many parts of England. 

(7) Mental Shock. — Mental shock is sometimes given 
as a cause, but only a hereditarily weak brain would be 
affected in this way. 

Impoverished conditions of the blood, rickets, and 
poor general health may have an effect on mental 
development, but produce backwardness and not feeble- 
mindedness. 

Conclusion. — Everything points to the conclusion 
that the acquired factors have probably little compara- 
tive effect in the causation or the determination of the 
ordinary or primary type of feeblemindedness, though 
they do directly cause some of the special types, such as 
the cerebral diplegic or the hydrocephalic. Primary 
feeblemindedness is inherited and is a failure of develop- 
ment, the brain being irretrievably unformed owing to 



196 ACQUIRED FACTORS 

an inherent defect in the germ-plasm ; therefore acquired 
causes, either natal or post-natal, have comparatively 
very little effect and, even the pre-natal acquired causes 
acting on the mother during pregnancy, in all proba- 
bility, act only as accessory conditions. 



CHAPTER XIV 

PREVENTATIVE MEASURES AND GENERAL SOCIAL 
CONSIDERATIONS . 

(1) Lifelong Care Essential. — We have seen that 
lifelong care is essential, and that the most forcible 
argument in its favour is that every feebleminded per- 
son, who is not under restraint, is a menace to the 
community; not only is such an individual very likely 
to become a so-called criminal, drunkard, or prostitute, 
but also he or she may propagate and spread a taint 
that is wholly bad by having children, legitimate or 
illegitimate. Obviously it is a necessity to prevent 
these unfortunate persons from coming into contact with 
those who are ever ready to take advantage of the weak- 
willed, and also to prevent them from becoming a prey 
to temptations which, by reason of their inherent weak- 
ness, they are unable to resist. Furthermore, surprising 
progress is often made under good tuition. The body 
and mind can generally be trained to some occupation 
which is useful in that it exercises the mind and trains 
the muscles. Later the child or adult learns to be of 
use in a workshop or farm, and in many instances to 
manufacture articles such as boots, clothes, mats, and 
cord or to do other useful work. 

Feebleminded children when occupied are probably 
happier than other children — happier in that they are 
simpler, more easily amused, and are burdened with 
fewer worries ; but they fall very low when no attempt 
is made to exercise their minds and bodies, and become 
a sight and example which often has a degrading and 
demoralising influence on those around. It is a very 

197 



198 PREVENTATIVE MEASURES 

noticeable fact that a child who has had training and 
has then passed out of supervision, soon goes downhill 
mentally and physically, since absence of occupation 
has a far greater influence on the feebleminded than on 
the ordinary child in leading to bad habits, dirtiness, 
and moral degradation. 

Efficient supervision and care should enforce (1) 
constant occupation, and (2) absence of temptation or 
of bad examples. Feebleminded persons are so easily 
led that they quickly copy bad examples and thus 
develop bad habits. On the other hand, if they are 
kept free from all vicious influences, they are just as 
readily guided into lines of good conduct. All schemes 
for treatment and training must be based on these 
principles and on the fact that feeblemindedness is not 
curable, so that training increases rather than diminishes 
the dangers unless lifelong supervision is enforced. 

(2) Lifelong Care. — It is only necessary to emphasise 
again one or two points. 

First, it is very important that feebleminded children 
should come under control at an early age before they 
have learnt bad habits and while their mental faculties, 
permanently crippled though they are, can yet be 
developed and trained on the right lines. To ensure 
this it is necessary : — 

(a) That feeblemindedness should be diagnosed early, 
and that efficient measures for ascertainment should be 
.in operation, and that parents should, if necessary, 
be educated how to care for and train their child. 

(b) That, as soon as it is old enough, the child should 
come under the care of skilled teachers so that its mental 
powers may be developed as much as possible. 

Special day schools at present play their part in (&), 
but, if children are to be trained at special day schools, 
some organization for lifelong care and control of those 
leaving is essential. There is no doubt that state- 
supported industrial colonies are the best from the point 



COURSES OPEN TO PARENTS 199 

of view of efficient care and prevention of the propaga- 
tion of feeblemindedness, but it will not be possible, for 
economic reasons, to provide colonies for all the feeble- 
minded for a long time to come. In chosen cases 
guardianship may be adopted, but, outside institutions, 
efficient supervision is very difficult indeed. It must 
always be remembered that the feebleminded need at 
all times to be carefully guarded from temptations, and 
the number of cases that are suitable for guardianship 
is only small. Boarding-out of feebleminded children, 
as it has been done in the past without efficient super- 
vision, can be whole-heartedly condemned, and the work 
of the After-Care Committee in Birmingham shows how 
little hope there is of feebleminded persons retaining a 
wage-earning post. 

(c) It can be readiiy seen that to attain the above 
there is need for education of medical men, teachers, 
and other workers, for education of public opinion, and 
for education of the parents and relatives of mental 
defectives. There is need also for progress in knowledge, 
and this can best be brought about by research. It is 
the duty of every State to provide grants in aid of 
education and of research. 

(3) Courses Open to Parents or Others wishing to 
put a Feebleminded Child under Care under Present 
Conditions. — Parents or guardians who wish to put 
their child under efficient care have several courses open 
to them, but an alleged mentally defective child has 
first to be examined by a certifying medical officer under 
the Elementary Education (Defective and Epileptic 
Children) Act, 1899, and the Mental Deficiency Act, 
1913, and the method of dealing with the case depends 
entirely upon the result of the examination by the 
certifying officer. 

The certifying officer may make any one of the follow- 
ing findings (see form of Certificates, pp. 255-257) : — 

(1) Normal and fit for an ordinary school. 



200 PREVENTATIVE MEASURES 

(2) Merely backward and dull, and requiring indivi- 
dual treatment in a special class for dull children. 

(3) Not able to benefit by instruction in an ordinary 
school, but a suitable case for a special day school. 

(4) A suitable case for a special residential school. 

(5) Requiring custodial care, i.e., idiot, imbecile, etc. 

The parents or guardians can : — 

(a) Pay for the maintenance of the child at a private 
or a charitably -supported institution.. 

(b) If they cannot pay the fees of such institutions, 
they can apply for the admission of their child as a 
non-paying patient to one of the institutions to which 
such cases can be elected. But the accommodation for 
non-paying cases is limited, and it is very difficult indeed 
to obtain sufficient votes to elect a child to such institu- 
tions. They can also present a petition to a judicial 
authority, asking to have the child placed under control. 
Here again accommodation is the difficulty. 

(c) They can apply to the Poor-Law Relieving Officer, 
who reports to the Guardians. The Poor-Law Authori- 
ties are, however, only required to provide for defectives 
in their area who are chargeable to the poor laws. For 
such of these as are mentally defective children the 
guardians make suitable provision, some being main- 
tained and taught at special residential schools by 
arrangement with the managers. 

(d) They can, through the Education Authorities, 
send the child, if of school age and educable, to a special 
residential school or to a special day school if there is 
one in the district. But the latter provision does not 
remove the child from home, and the parents usually 
seek to place the child under control because it is too 
much for the mother to manage or its behaviour is 
reacting harmfully on the other children. 

(e) They may, if able to afford it and if they can 
satisfy the Local Education Authority that the child 



SIZE OF FAMILIES 201 

is under sufficient instruction, employ a tutor and keep 
the child at home. But such provision is not lifelong, 
and a feebleminded child is better as a member of a 
community than as a single pupil. Also, he should enter 
that community at an early age. 

(4) Size of Families containing Feebleminded 
Children. — The parents of feebleminded children are as 
a rule slightly more prolific and have larger numbers of 
children than the average. 

In 500 families (some of them not complete) each con- 
taining one or more feebleminded children, there were 
3,018 children, an average of 6 to each family. The 
average number of children in the families containing 
Mongols was about the same, and these families are 
usually large. In England thirty years ago the average 
number in a family was stated by the Registrar General 
to be 4.6, and it is probably less now, but we must not 
forget that the Registrar General's Report included all 
classes, while the other figures are taken from the lower 
classes, where large families are much more common. 

The Eugenics Laboratory Memoirs X. states that the 
average size of the families in Edinburgh is 6.11, and 
that of Manchester families containing mentally 
deficient children 6.14. 

From these figures it can be seen that the families 
containing mentally defective persons tend to be large 
rather than small, and that a considerable number of 
the mentally defective survive. 

(5) Likelihood of there being other Feebleminded 
Children in a Family containing one such Child. — 
A question of very great importance often asked by the 
anxious parent is : " Are future children who may be 
born to parents of a feebleminded child more likely to 
be feebleminded than the average child?" There is 
no doubt that they are more likely to be so affected, 
the proportion working out at 1 in 55 as against 1 in 80 
of the ordinary Manchester children. 



204 . PREVENTATIVE MEASURES 

great improvement in the health of the individual. But 
evidence is forthcoming that it often leads to a great 
increase of crime and vice of certain kinds, and that, in 
women, it generally increases mental weakness. Dr. 
Fernald sums up that it is not a good measure, that it 
is liable to abuse, and that it may encourage vice and 
venereal disease. If children come under control early 
enough, such measures should not be necessary in insti- 
tutions. Discipline, cleanliness, and absence of sugges- 
tion is, in most cases, a sufficient safeguard. 

The operations in themselves are not necessarily 
dangerous, but opinion against any such surgical 
measures is very strong and rightly so, one difficulty 
being that such an operation, if once adopted, might be 
unjustifiably extended or abused. 

Sterilization might be necessary as a preventative 
measure if lifelong care were not available, for there is 
undoubted danger to the community from the large 
numbers of feebleminded who are not under supervision 
and who are specially liable to have illegitimate children 
or to make ill-advised marriages. But the disadvantages 
of such a procedure are great, and lifelong supervision, 
which, though more costly, is so necessary for other 
reasons, should, if efficient, be an equally good safe- 
guard against the propagation of the taint to future 
generations. 

Those who are working for these unfortunate human 
beings, and who in bad cases, when the results of 
tuition and training are particularly disappointing, 
doubtless wonder whether they are really doing any 
good or not, must realise that all cases cannot be raised 
to such a level that they are able to do useful work. 
Teachers and others must be encouraged by the fact 
that any efforts that promote discipline and mental effort 
in the feebleminded are of distinct value in keeping them 
from falling to low depths of degradation and vice. 
Surely it is worth an effort when we consider that, if 



SUMMARY 205 

left to themselves, many of these children, instead of 
being healthy and at least clean, become, not more like 
beasts than men, but worse than beasts. One has only 
to visit the houses of the cases rejected as too bad for 
the special schools to realise the truth of this and to be 
appalled by the urgent need of effective remedies. 

Summary. — (1) Efficient lifelong care and super- 
vision is absolutely essential. 

(2) The legal powers of controlling the feebleminded 
are even now insufficient, and those which do exist are 
not used to their fullest extent. 

(3) It is very difficult indeed for parents, who are un- 
able to pay fees, to find accommodation for their feeble- 
minded child in any suitable institution. 

(4) A system of special schools, colonies, and, in very 
few selected cases, guardianship combined with univer- 
sal classification and registration is needed, and for this 
teachers, visitors, and other workers must be trained. 
Grants for research work should also be provided. 

(5) The families containing feebleminded children tend 
to be large. 

(6) The remaining children in a family containing a 
feebleminded child are more likely to be mentally defec- 
tive than are children in other families, the Mongolian 
type of mental deficiency forming an exception to this 
rule. 

(7) There is grave risk in the marriage of the blood 
relations of congenitally feebleminded persons, even if 
they marry into a good stock. 

(8) Surgical sterilization is neither desirable nor 
necessary if efficient lifelong care is enforced. 



208 APPENDIX I 

play. It is well to remember that, for the feebleminded, 
all work may be made as delightful as play, and that 
our object is not attained until our children look forward 
to their daily business with as much interest as to their 
games or their dinners. 

All the children retained in residential institutions 
should be busy and happy until the time comes when 
they are disabled by illness from taking their share of 
the work of their home. Then they should still be 
happy and good. If they have been properly trained, 
it will make them easy to nurse and comfort when they 
are in the grasp of illness. 

I have thought it well to put down at the beginning 
of these notes what are my views upon this subject. 

It is very desirable that a colony should have accom- 
modation for all grades of mental defect, both because 
classification will then be easier and more efficient and 
for the sake of economy. In any colony where houses 
for all grades exist it will certainly be found that fre- 
quent re-classification is necessary if injustice is not to 
be done to individual cases. Some improve and some 
deteriorate. It is an economical arrangement which will 
allow of the work of high-grade patients being utilised 
for the service of low-grade patients. 

Admission. — When a child is admitted to a residen- 
tial school with a view to its remaining for life in the 
colony of which that school should form the foundation, 
the first thing to be considered is its bodily condition. 
Weak-minded children coming from poor homes are 
commonly in a poor state of health. The doctor who 
passes the child as suitable for residence in the colony 
will satisfy himself as to any special weakness that 
requires attention, and will point out to the nurse or 
matron what he wishes to be immediately done for the 
child's physical benefit. There are, however, some 
troubles which it is for the matron rather than for the 
doctor to set right. 



BATHING 209 

So soon as the child has been examined and passed, 
it should be given a warm bath. Great care should be 
taken to do the bathing very gently. It must be 
remembered that many such children have never before 
had a bath, and that it is, to them, an alarming thing 
to be put into water all over. If, however, they are 
allowed to feel the pleasant warmth of the water before 
they are completely immersed in it, and if their attention 
be distracted while they are being undressed, the 
difficulty can generally be got over. The water must, 
of course, be carefully tested to make sure that it is not 
hot enough to cause the least sensation of pain. A 
thermometer should hang in the bath-room for the 
purpose. The water should not exceed a temperature of 
98° to 100° F. 

It must be remembered that it is possible that the 
child may be insensitive to pain, and might be severely 
scalded without crying out. A gaily-dressed doll or 
other toy should be within sight of the child, and should 
be given to it when the washing and dressing are over. 
It must be borne in mind that such children can be 
bribed with toys long after the age at which normal 
children discard them. A Teddy Bear has sent to sleep 
many a little one who without it would have cried 
itself ill. 

When the child has been thoroughly bathed and 
examined for any bodily defect that may have escaped 
notice during the preliminary examination, it should be 
warmly wrapped up and its hair should be cut quite 
short. Sometimes it may be better to cut the hair 
before bathing. It is frequently necessary to completely 
shave the head in order to get rid of vermin. If any 
lice are found on the body, it will be necessary to 
destroy or, if they are good, to stove the clothes in 
which the child was brought to the school. In any case, 
if lice have been found, the child must not be put back 
into its own clothes, however clean they may appear to 
o 



210 APPENDIX I 

be. It often happens that the child has been re-dressed 
for its journey in clothes given by some charitable 
person, without having had its body washed. 

A warm and comfortable meal should follow on the 
bathing, and it is to be hoped and, in some cases, 
expected, that the little one, worn out with all the 
experiences of the day, will go to sleep as soon as it is 
put to bed. It is likely that it has never slept in a 
bed by itself before, and this may prove a source of 
distress to it. Care should be taken to place it in the 
dormitory between children who will speak kindly to 
it should it feel frightened — unless, indeed, it should 
have been heard swearing or using foul language whilst 
being dressed. In that case it is best to place it between 
two of the dullest and least observant of the children 
in the room. Sometimes it is necessary to isolate a 
child for a time in a sick-room or hospital until it has 
forgotten its bad habits of speech. 

On the day succeeding its admission the child will go 
to school, and its life at the Colony will have begun. 

Food. — With few exceptions it is possible and desir- 
able to insist upon all the children in a colony, young 
and old, eating the food which is provided for their 
table. It is very usual for parents to say : " My boy 
cannot eat this or that article of diet." No plea for 
differential treatment in this matter should ever be 
admitted without very good reason. (Such as that 
vegetables or porridge or jam cause diarrhoea.) 

Tea, coffee, and alcoholic stimulants should be 
absolutely avoided except as medicines or, in the case 
of tea or coffee, as a very rare treat. It is a great 
pleasure to a child who is a little out of sorts to have 
a cup of tea, with bread and butter cut rather thinner 
than usual. 

Meat should be given in small quantities, and what is 
given should be made into a stew or broth and poured 
over the vegetables. Some people prefer to give meat 



DIET 211 

minced; in any case it should be in a form which does 
not make it difficult to masticate. 

A good and sufficient dietary is the following : — 

Breakfast. — One morning porridge and milk, and the 
next bread and milk. Bread and butter to follow if the 
child is still hungry. 

Dinner. — Two or three vegetables, including potatoes, 
with a stew or broth poured over them. Bread to eat 
with them. Pudding to follow, either milk pudding, jam 
or suet roll, or stewed fruit. Sometimes milk pudding 
and fruit may be given together. 

Soup, fish, and baked beans,* instead of meat, may 
each be given once a week so as to secure variety. 

Tea. — Bread with margarine, jam, or treacle. Lettuce 
when available ; milk to drink. It is well to insist upon 
the bread and butter being eaten before the bread 
and jam is attacked. 

It is necessary to note that it is not safe to allow all 
children to eat as much as they like, even of plain food. 
A case is on record of a boy who ate ten rounds of bread 
from a four pound loaf. 

Boys going out to work should have a lunch of bread 
and cheese to carry with them. Girls working in the 
laundry should have a lunch of hot milk with a very 
little coffee and bread and butter. This exception is 
made because the girls see the women who work with 
them have this lunch, and think a great deal of being 
old enough to have it also. It is easy to make the 
coffee so weak that the children are drinking almost 
entirely milk. Should any child coming in from work 
not eat his or her dinner, it is well to stop the lunch 
for a day or two. 

If the children have a pint and a half of new milk 
a day each, in addition to solid food, we may be sure 
that they are not underfed. In winter, cocoa may some- 
times be substituted for milk. 
* The beans are baked with bacon, after the Boston receipt. 



212 APPENDIX I 

Children should feel at liberty to ask for a piece of 
bread and butter at any time; but they must not be 
encouraged to eat between meals and then to play with 
their food at regular meal times. 

With regard to the eating of sweet things such as 
toffee, chocolate, and the like, care should be taken that 
all sweets given to the children are wholesome. Relatives 
and friends often bring sweets for the children in whom 
they are interested ; these should be taken possession of 
by the matron, except just enough to make the child 
feel that he has had his treat. He should be encour- 
aged to share all he gets with others. This is a safe- 
guard against his having too much and a lesson against 
greediness. All food should be nicely cooked and 
properly served. Table manners form an important part 
of the child's education. They should, from the very 
first, be taught to eat decently and not to be greedy. 
A good deal of trouble taken about this in the beginning 
will be well repaid. 

Grace should be said quietly and slowly. The 
children should not begin to eat until they are told to 
do so. They must be taught to pass the plate to 
others before helping themselves and not to take the 
largest piece. It is a matter of some difficuly to teach 
them to hold their knives and forks properly and not 
to spill their food. All children should be given knives 
as well as forks so soon as they are able to use them. 

The children should on no account be allowed to talk 
at table. It is sometimes urged that conversation 
during meals is more homelike than silence, but, where 
any large number of boys or girls are gathered together, 
conversation soon degenerates into chattering; voices 
are raised, and the children shout one against the other. 
Confusion results from the noise, and it becomes im- 
possible for the attendants to supervise properly the 
manners and behaviour of their pupils. Moreover, 
children who are talking are likely to bolt their food 



MEALS 218 

without mastication ; this is always a fault of the feeble- 
minded, and is the cause of many of the small ailments 
from which they suffer; so far as possible it should be 
checked, and the boys and girls should understand that 
whilst they are at table their business is to eat, not too 
fast, but quietly and in orderly fashion. 

At Waverley, Mass., U.S.A., the children's meals are 
served at tables accommodating ten each. The food is 
placed on the table in such an order that the attendant 
in charge can see at a glance whether it is all there. The 
attendants do not sit down, but move about the room 
helping and watching the children. It must be re- 
membered that at Waverley all grades of mental defect 
are admitted. Even the very lowest are taught to eat 
fairly decently. Some of the high-grade boys and girls 
are told off to help the weakest of the low-grade cases, 
whose meals, it is unnecessary to say, are separately 
served in their own houses. The high-grade children, as 
in England, have table-cloths. The low-grade cases 
have their plates or bowls placed at one end of a long 
napkin, the other end of which is tied round their necks 
like a feeder. In this way any droppings from the spoon 
or mouth are easily collected and removed after the 
meal is over. 

At Sandlebridge we find it necessary to give some of 
our children feeders. Our children are served at long 
tables, covered with cloths. The first course is actually 
served in the kitchens, and is carried into the dining- 
rooms by children whose special duty it is to wait at 
table. The second course (the pudding) is served at 
table. 

After a little trouble the children learn that they must 
eat everything which is set before them, so that there is 
very little waste of food. 

Care is taken that the older, or working, children 
have larger platefuls than the little ones, and that each 
child is suitably helped. 



214 APPENDIX I 

It is desirable that the Medical Officer should from 
time to time satisfy himself that the quantity and 
quality of the diet given is in accordance with that laid 
down by the Board of Control. Should it be unsuitable, 
however, the children soon show the fact by their dim- 
inished vitality and lower state of health. 

Cod-liver oil is so much a food that it may be proper 
to speak of it in this connection. When winter sets in 
it is common to find that many of the children fail a 
little ; they begin to have chilblains and look pale and 
out of sorts. Tempers begin to be tiresome. This may 
be taken as the signal for beginning to administer cod- 
liver oil. Almost all children like it, and as a rule 
they quickly show its good effects. 

Dress. — It cannot be too constantly remembered that 
children who are weak in intellect are apt to be weak 
in body also. Especially they are apt to have poor 
circulations and to suffer from cold hands and feet. 

It is hopeless to attempt to get any good work or 
good play from a child who is cold. 

Clothing should, therefore, be ample. It should not 
be too heavy nor should it consist of too many garments. 
For the boys great comfort and security against chills 
is obtained by putting them all into grey flannel shirts. 
(It must not he supposed that flannelette will answer 
the purpose.) 

A clever matron will so arrange that the new shirts 
are taken into use at the beginning of the winter. In 
the winter also a waistcoat may be worn, which can be 
left off in the summer. If this be done there will be 
no time of the year, in this climate, when flannel shirts 
will be too warm. Boys at school should wear a dark- 
blue jersey as their top garment on week-days, with 
knickerbockers and long stockings. Working boys wear 
a coat instead of a jersey. 

Dress for boys may be given as this : — School 
children : Flannel shirt made long enough to come well 



♦CLOTHES 215 

over the hips; long black woollen stockings; cloth 
knickers, without pockets, lined with grey calico ; cloth 
waistcoats and dark-blue jerseys; strong shoes for the 
house and boots for out-door wear. Nightshirts should 
always be provided, with vests under them in cold 
weather. For Sundays cloth suits should be worn, with 
white collars and gay neckties. For very little boys it 
is worth while to provide sailor suits. They do not cost 
more and look better for small boys than the ordinary 
knicker suits. 

For working boys corduroy suits should be provided 
if their work is of a rough nature; otherwise they may 
wear cord trousers or knickers (according to their 
height) and cloth waistcoats and coats, over grey flannel 
shirts. It is a tidy plan to have these big boys' shirts 
made with a turn-down collar. The trousers, which can 
no longer be so constantly washed as when the boys 
were little, must have linings of grey cotton, buttoned 
in; these linings need not come below the knees. Thick 
socks may gradually be given in place of the long stock- 
ings. Great attention must be paid to the fit and con- 
dition of boots. Clogs may be used for farm boys. Cloth 
caps are the best head-gear, except in very hot weather, 
when linen hats may be worn. Linen jackets, which can 
be frequently washed, are useful in hot weather. 

Nice Sunday suits should always be given, and the 
boys should be encouraged by every possible means to 
care for their personal appearance. 

It is especially necessary, in the case of the little boys 
to take care that no part of the clothing presses unduly 
on the person. Bad habits may be set up merely by 
the fact that the child is wearing a pair of knickers 
which are too tight for him. 

Warm great coats or capes should be provided for use 
in wet weather. 

Girls should have warm woollen vests next to the skin ; 
the garment next to that should be a pair of thick cotton 



216 APPENDIX I 

combinations. Over this should come a good flannel 
petticoat with a body to it. Then a stuff petticoat. In 
this climate nothing is better for ordinary wear than 
blue serge frocks. These should be prettily made and 
protected by cotton pinafores or aprons, according to 
the age of the girl. All girls will require three frocks — 
one for school or afternoon, one for work, and one for 
best. No stays are necessary or desirable except in the 
case of some special deformity which is to be helped or 
corrected by special corsets. Vests must be worn under 
nightgowns in the winter. Warm capes should be pro- 
vided for cold weather. Jackets do very well for some 
children, but where the child has a difficulty about dress- 
ing it is a saving of time and trouble to use a garment 
for outdoor wear that has no sleeves. Grown-up work- 
ing girls require cotton working dresses. The greatest 
difficulty about the girls' dress, from the point of view 
of neatness, is as to the finish of the frocks at the neck. 
A good plan for working dresses is to have them made 
with a little turn-down collar. In any institution for 
girls many gifts of clothing will be received; these may 
be utilised with advantage; there is no object in having 
all dressed alike; care, however, must be taken that 
uniformity of warmth is secured. Long woollen stock- 
ings should be provided, and good, well-shaped boots 
and slippers, with clogs for laundry girls. Hats are a 
difficulty when heads are peculiar in shape and size. 
Gay cloth caps (red and blue) are the most satisfactory 
on the whole. If there be any very hot weather, linen 
hats may be used. 

All feebleminded children, boys and girls, should be 
encouraged to pay much attention to their persons, and 
vanity should be cultivated as a saving grace. 

Dormitories. — These should be warm and airy and 
well lit. They should be very easy to keep clean, and 
therefore should be so constructed and of such materials 
that any dirt is likely to be visible. If possible, a tiled 






BEDS 217 

dado, in a bright colour, is good; it is both sanitary 
and decorative. A bright linoleum on the floor, regu- 
larly treated with ronuk or some equivalent, is desir- 
able. Polishing this is one of the earliest forms of work 
that the children can be put to. A line of little boys 
or girls can quickly polish a large floor-space and will 
enjoy doing it. 

Whilst the children are young, it is best to have 
nothing in the dormitory but the beds and the necessary 
chamber utensils. All the children should be washed 
in a lavatory. Beds must be warm and comfortable : 
it must always be remembered that nothing so conduces 
to the wetting of beds as cold. The best thing for the 
children to lie upon is very thick felt over a wire 
mattress. (The felt sometimes sold for this purpose 
having become very expensive, an equally good effect 
may be obtained by putting two thicknesses of ordinary 
felt together, secured by eyelets at the corners through 
which strings are passed to tie the felt to the bedstead.) 
Under the felt should be strong brown paper, both to 
preserve it and for extra warmth. Over it should be a 
thick brown blanket; then come the sheets (brown 
Bolton sheeting is the best, it is soft and warm). Then 
should come as many blankets as are necessary for 
warmth and then the quilt. The pillow should be low. 
Bolsters are not necessary. In the " sick-room " 
mattresses are desirable. 

Windows should be open all night all the year round. 
If open fires are used these should be lit in time to warm 
the dormitory thoroughly before the children go to bed 
and then allowed to go out. 

There should be a bright picture or two in the dormi- 
tory and a few toys on the mantel-piece. 

Dormitory discipline is very important. The children 
should begin on admission to learn to fold their clothes 
neatly and lay them in a pile at the foot of their beds. 
It often takes a long time to teach this, but when it 



218 APPENDIX I 

has been successfully accomplished the child has learned 
several important lessons; how to use its hands and 
eyes, how to copy what it is shown, and, not least, it 
has achieved the beginnings of neatness. 

The children must also learn to make their own beds. 
Every bed must be quite stripped every day. Each 
child while small should make its own bed ; it would 
be a pity if any one missed so practical a lesson. When 
they are older it is a saving of time and trouble to allot 
the dormitory work to special children. 

They must learn that they are never to leave their 
beds without necessity. Also they must be taught that 
they must leave them when it is necessary. Children 
often wet their beds from sheer laziness or because they 
are afraid to get out of bed in the dark. If a child wets 
its bed, it must be regularly got up the last thing at 
night before the attendant finally leaves him. Children 
soon learn to get out of bed, almost without waking, 
so soon as the light is turned on. No pains should be 
spared to cure the bad habit of wetting the bed. It is 
undoubtedly impossible to get it under in the case of 
many imbeciles, but almost all children who are able to 
learn to wash and dress themselves can be made to be 
clean in their habits. Judicious discipline will often 
work wonders, just as it will in the training of an infant; 
but it must be remembered that the punishment, to be 
effective, must follow close enough upon the offence to 
be connected with it in the child's mind. It is a good 
thing to give children who wet their beds their last drink 
somewhat earlier in the day than the others. A sharp 
run just before retiring, or other exercise such as 
skipping, which will induce a light perspiration, is help- 
ful. If discipline, encouragement, and other simple 
means fail, the doctor's assistance should be asked. I 
have known one boy, suffering from kidney trouble, 
who was much benefited in this respect by wearing a 
flannel bandage round his body. A light should be 



BATH-ROOMS 219 

always kept burning at night for young children and 
those who are liable to be taken ill. 

Should a child constantly and incurably pass faeces 
under it in bed it will probably turn out to be an 
imbecile, and should be in an institution with others 
of the same mental grade, or, better still, in a special 
house for such children where special supervision is 
given, rather than in a school for those who are technic- 
ally named feebleminded. 

Talking or playing in bed must be rigidly discouraged ; 
the children should learn that they go to bed in order 
to go to sleep. Nothing should be taken to bed except, 
in the case of little ones, a toy or doll to hug. 

When the attendant goes the round at night he should 
observe whether the children are lying with their heads 
properly uncovered; the children should not be allowed 
to burrow to the foot of the bed and bury themselves 
in the bed-clothes. 

Bath-rooms and Lavatories, — Bath-rooms should be 
as ample in space and accommodation as circumstances 
will permit. It is often a matter of some difficulty to 
get all the children in a large home bathed often enough, 
especially when some of them have to be bathed much 
more frequently than others. At Waverley, Mass., 
only shower-baths are used. It is a plan that has 
undoubted advantages. Care must be taken from the 
beginning to make all the children observe decency in 
their bathing. One of the most marked signs of a weak 
intellect is a willingness to expose the body improperly. 
Especially with the older girls it is impossible to take 
too much trouble about decency and privacy in the care 
of their persons. Where there are two or more baths 
in a room a screen should always be used so soon as the 
girls approach womanhood. Whilst they are still quite 
small they can be taught never to entirely expose their 
persons. They should learn to put on their night-gowns 
before they altogether remove their day clothing, and 



220 APPENDIX I 

to wrap themselves in their towels directly they leave 
their baths. 

All children should be bathed often enough to secure 
cleanliness. It will be found an advantage to have in 
the bath-room small fixed earthenware tubs in which 
the feet and legs may be washed without giving a com- 
plete bath. Especially boys who are out at work will 
get their feet very dirty. 

With the young children it is a good plan, on the 
days when they are not having a bath, to give them 
their strip wash in the lavatory before tea. They can 
then go to bed immediately after tea and prayers are 
over, and the attentions of the persons looking after 
them can be more easily devoted to getting them pro- 
perly to bed than when they have to look after their 
washing and also after the bathing of those whose bath- 
night it is. Teeth should be cleaned at night. How to 
manage tooth-cleaning and to keep tooth-brushes clean 
and in nice order is always a problem. At Waverley 
the brushes are kept in a frame pierced with a hole for 
each brush. The attendant stands with the frame, and 
each boy or girl comes for his or her brush and after 
using it returns it to the attendant. 

At Sandlebridge we use a row of clips or a pierced 
frame above the basins in which the children wash. It 
is significant that the boys wear out only half as many 
brushes as the girls. 

Heads are an endless difficulty; however carefully 
they are cleansed and watched there is always the 
difficulty of possible re-infection from a visiting parent 
or friend. It is, of course, nice to be able to allow 
the girls to wear their hair long; but it is a question 
whether the advantage gained in appearance is not out- 
weighed by the endless trouble given if infection creeps 
in. Also, leaving that aside, there are very few girls 
who can learn to take care of their own hair; and it 
is a great addition to the work of the staff to keep many 



LAVATORIES 221 

heads of long hair in neat and pretty order. A very 
pleasing result may be obtained by giving the girls who 
have their hair short bright-coloured bows of ribbon on 
elastic to wear. 

If the children's heads are perfectly clean it will not 
be necessary to have in use a comb and brush for each 
one. There are advantages in having only so many in 
use at once as are wanted for the nice keeping of the 
children's hair. Both combs and brushes are frequently 
broken, and it is by no means easy to keep up a constant 
supply in a large home if each child has one. When 
only a limited number are used, they can be replaced 
as soon as they are spoiled. 

Needless to say that a sore head, skin trouble, or eye 
trouble necessitates a separate brush and comb kept 
where it is inaccessible to the other children. 

The same remarks apply to towels. Probably there 
are as many ways of managing these details of the 
toilet as there are institutions. One thing is certain, 
if the child be completely cleansed immediately after 
admission, all subsequent arrangements of this sort are 
much easier than they otherwise would be. 

Whether the child has its own towel or no, the towels 
should never be allowed to remain very dirty. It is 
bad morally as well as physically for a child to use any- 
thing which is obviously unclean. 

The bath-rooms and lavatories should be specklessly 
clean; the keeping of them so provides work for low- 
grade cases. Boys and girls of very small capacity can 
learn to polish taps and to wash tiles. 

There should be a good supply of hot and cold water. 
If the taps are not of the kind that can be only turned 
on with a key by the attendant, great care should be 
taken that the children do not have the chance to scald 
themselves with the hot water. Here, as everywhere 
in the institution, it is well to be on the look-out for 
an accident. 



222 APPENDIX I 

Offices, — Perhaps there is nothing in the care of the 
feeble-minded which calls for more attention than the 
use of the offices. Where, as in America, they are in 
the same room as the lavatories and attached to the 
dormitories, it is comparatively easy to see that the 
children use them properly. There is, however, so much 
to be said in favour of having them entirely removed 
from the dwelling-rooms of the house and of having 
them detached and separate, that this ease may be con- 
sidered as rather dearly bought. 

With regard to the little children, it is not a bad plan 
to utilise the services of an older child. It must be 
made quite sure that this child is to be trusted. The 
offices must be sufficient in number and readily acces- 
sible. Two children should never be allowed to enter 
at once, except in the case in which an older child is 
acting as nurse. 

So small a detail as the proper use of paper, without 
waste or untidiness, when achieved, marks a distinct 
advance in the progress of the child towards civilisation. 
Paper should always be hanging in each office, neatly 
cut and ready for use. The cutting of this paper makes 
an occupation for a low-grade case. Big boys and 
small ones should not use the same offices. If a child 
appears to be poorly the first thing to be done is to 
make sure that it is not suffering from constipation. 
In order to do this it will probably have to be isolated 
in the sick-room or hospital for a few days so that it 
may be under careful observation. Decency in the use 
of the offices, as in bathing, should be carefully insisted 
on. If a child is careless and soils its clothes in using 
the office or from neglecting to use it, it is a good plan, 
supposing that he has the physical strength for the work, 
to make him wash out the soiled garments himself. It 
is often pure laziness that makes a child dirty in this 
way; sometimes, when they come from other institu- 
tions where perhaps the necessity of training has not been 



DINING AND DAY ROOMS 223 

realised, they are wilfully dirty. One boy said to the 
matron of his home at Sandlebridge : "I always have 
been cleaned up after, and you will have to clean up 
after me too." He had to alter his view of the subject. 

Children can early learn to clean out their own offices ; 
they must be taught that it is as important to keep 
these in nice order as it is to keep their day-rooms and 
even " Matron's sitting-room " neat. 

Dining and Day-rooms. — Whilst the children are 
small it is important to have separate dining and day- 
rooms for them, as they will have to spend bad weather 
indoors and must have somewhere to play. When they 
are grown-up and going out to work probably one large 
room will suffice. Both day and dining-rooms must be 
warm and light. All lights must be well out of reach of 
the children and open fire-places must be guarded. It is 
desirable, from the point of view of cheerfulness and ven- 
tilation, to have open fire-places, but care must be taken 
that the children do not hang round them too much. 

Neither room should be over-furnished. There 
should be nothing in the dining-room but tables, chairs, 
and pictures on the walls. 

In the day-room there should be a good solid table, 
some chairs, and a cupboard for toys. There should 
also be a piano and a couch (very simple, a camp-bed, 
with a squab covered in American cloth answers every 
purpose) for an ailing child to lie down upon. Pictures 
on the wall and a few of the best toys on the mantel- 
piece complete all that is necessary for this room. It 
is, however, very good for boys and girls if there is a 
rocking-horse provided. 

If the room should be for quite little children, the 
large table may be dispensed with; little children like 
to play on the floor. There should, however, be several 
very small tables and little bent-wood arm-chairs which 
can be drawn close to the fire for an invalid or delicate 
child. 



224 APPENDIX I 

The floor should be covered with bright and cheerful 
linoleum and the walls should be light in colour. Too 
much stress cannot be laid upon the desirability of 
having all the rooms which are to be inhabited by feeble- 
minded children light, pretty, and warm. It is a great 
mistake to suppose that it is more economical to have 
them ugly than it is to have them pretty. 

The children should early be taught, so far as possible, 
to put away their own toys, and to realise that they 
must respect the property of each other. They must 
also be taught that they must share all the gifts that 
are brought to them by relatives and friends. Gifts of 
food must not be kept in the day-room, but must be 
immediately taken possession of by the matron and 
given out discreetly. 

Wardrobes. — These should be ample in space and 
accommodation. They should be well ventilated, and 
it must be remarked that it is not a good thing to shut 
away the clothes, especially the cloth clothes, of the 
children. They are best hanging from an iron clothes- 
rail in the middle of the room. Wherever possible, a 
great deal of labour is saved by having the children's 
under-clothes put away in separate pigeon-holes, labelled 
with the owner's name. This is especially desirable in 
the case of the bigger boys and girls, who can be made 
to put away their own things and to keep their little 
cupboard tidy. When the girls reach womanhood, it 
will be found a good plan to give them certain privileges 
in this direction; perhaps a share of a little chest of 
drawers which may stand between two beds. Boots 
should never be shut up. They are apt to smell very 
unpleasantly if they are not exposed to the air. The 
best plan is to have a shelf or row of shelves made, not 
solid, but of slats with spaces between them. It is 
exceedingly difficult to keep the children tidy as regards 
their feet. Buttons are always being wrenched off; 
laces are constantly broken and mis-applied. On the 



I 



m* 



KITCHENS 225 

whole, boots that lace are probably the best, and the 
attendant in charge will have to keep a supply of laces 
on hand and try to prevent their being converted into 
whip-lashes, etc. 

In voluntary institutions there is rarely any very 
large stock of clothes on hand; the sooner, however, 
that a reserve stock can be arranged for, the better. It 
is economical to insist on order and neatness in the 
wardrobes. Time is lost when the attendant has to 
turn over a dozen piles of clothing before she can find 
what she needs. A Stock list should be taken regularly. 

Kitchen, Store-rooms, etc. — It is not my purpose to 
say much about these. They will vary in every case 
according to the size of the institution and the means 
at the disposal of the managers. It is worth while to 
remark, however, that here is the greatest opportunity 
for waste or for economy in the whole institution. A 
little waste every day makes a very great deal in the 
course of a year, and if the hearty co-operation of the 
servants who serve in the kitchen can be obtained, the 
successful working of the institution from a money 
point of view will be greatly helped. It is thought by 
some people that a central kitchen serving all the houses 
of a colony is the best arrangement. I believe, on the 
contrary, that a kitchen in each house is more economi- 
cal and convenient, as it is certainly more home-like and 
better for the boys and girls. 

In the kitchen, as elsewhere, the services of the 
children may be early utilised. They can wash tiles, 
clean taps, and wash up the utensils they have them- 
selves used at meals. They can lay their tables and 
carry the food to the tables when laid. Strong working 
aprons must be provided for boys and girls working in 
the kitchen, and care must be taken that they do not 
wet themselves too much in washing floors, etc. It is 
very difficult to get them to remember that they must 
use a kneeler, but it can be done; pieces of carpet tied 
p 



226 APPENDIX I 

with string round the knees are good in the case of boys. 
Great care must also be taken to prevent them from 
having unguarded access to the fire. They are rarely 
timid enough or cautious enough to be trusted not to 
hurt themselves. 

In any large institution the peeling of the potatoes is 
a serious business, and is one that can be well done by 
the children themselves. Great waste, however, can be 
avoided by the use of a machine for this work. At 
Sandlebridge the use of such a machine has resulted in 
a considerable saving of potatoes every week. More- 
over, it has provided a special kind of work for two boys 
who appeared to be useless for anything else. W. G. G. 
has a partially paralysed arm, of which he has hitherto 
made very little use. He turns the potato peeler, and 
has to bear all his weight on both arms as he does it. 
He is made to put the bad hand as well as the good 
one on the handle, with the result that it is growing 
visibly in size and is much stronger. His partner, 
L. P., was useless for any kind of work until this was 
found for him. He is improving in physique with the 
definite daily exercise. Both work under the direction 
of a high-grade boy, W. B., who attends to putting the 
water and the potatoes into the machine and afterwards 
carries them out to the different houses in a little hand- 
cart. These boys got so wet over their work that they 
are now covered completely with over-alls made of 
coarse strong material. 

Utensils. — Cups, plates, and basins should be of strong 
earthenware. Enamel is more durable but soon gets 
chipped and unsightly. Once chipped it is difficult to 
keep it quite clean. It seems likely also that chips of 
the enamel, getting into the children's food and being 
swallowed by them, may be the cause of serious illness. 
Moreover, if a child drops a plate or cup and does not 
see it break, as in the case of enamel, he will be less 
distressed by the result of his carelessness and more 



SCHOOL-ROOM 227 

likely to repeat it than if he sees the object broken to 
pieces. 

The utensils, however, in use in the dormitory may 
be of enamel, if due care be taken to exchange them for 
new ones so soon as they are damaged in a manner that 
makes them insanitary. 

It is well that the children should learn to take care 
of the utensils they use, but the process of learning will 
always be a costly one. The best punishment for care- 
lessness resulting in a breakage is to make the child 
hand over the next penny he receives, explaining to him 
that someone has to pay for the new cup or plate. 

The School-room. — It is most desirable that the 
school-house should be built quite apart from all the 
residential buildings of the colony. It is a great factor 
in the health of the children that they should be obliged 
to leave the house in which they live twice every day. 
It is not only that the fresh air lessens their liability to 
consumption, but also that it strengthens them in every 
way; especially they are less likely to take cold when 
they are constantly out of doors in all weather. Com- 
mon colds are a great nuisance in an institution, and 
anything that lessens their frequency is a boon. It is 
also much better for the teachers to have the school- 
room quite apart from the living-rooms. 

Should the school be under the Board of Education, 
it will, of course, have to conform in space and general 
accommodation with the regulations laid down by that 
Board. 

With regard to the decoration of the rooms, they 
cannot be too bright and pretty. Plenty of light, plenty 
of warmth, and plenty of floor-space are necessary. 
Care must be taken that the seats provided are comfort- 
able, and that a proportion of them can be readily 
moved. A number of small chairs for the very little 
ones or those who are deformed should be available. 
There should also be a couch or mattress, such as is 



228 APPENDIX I 

provided in the houses, so that a child who is taken ill 
may lie down at once. If there are children in the 
school, as is too likely, who suffer from epilepsy, it is 
not enough after a fit that they should be able to lie 
down when they go home. They should lie down im- 
mediately and be allowed to sleep the effect of the fit off. 

A good manual room is a great addition to the build- 
ing. This room may be used also as a sense-room. 
Perhaps it may be well to explain what is meant by a 
sense-room. Probably few institutions, at least few 
voluntary institutions, could afford to have a fine room 
specially set aside for this purpose, but if that at 
Waverley be described people can adopt the method if 
they think good. 

Dr. Fernald has furnished this room with large tables 
which stand out from the wall into the centre of the 
room. There is one for each of the five senses — sight, 
smell, hearing, taste, and touch. Against the walls are 
labelled cupboards for the necessary articles with which 
to test and train the child's senses. Thus, there are in 
the sight-cupboard a variety of objects, similar to the 
usual kindergarten bricks and models, but made at least 
three times larger than these. The brick is six inches 
in length by one inch square; the cones are six inches 
high; all are made on this scale. There is a great 
variety of models,* and all are gaudily coloured in the 
primary colours and are made in duplicate. (Dr. 
Fernald has a box of bright-coloured building bricks in 
every house in his colony. The children themselves 
make these bricks.) The child stands at the table, on 
which the different models are set out ; he is given, say, 
a red brick; it is large enough for him to grasp it 
easily and bright enough for him to see it clearly. He 
is told to move round the table until he finds another 
model exactly the same in shape and colour. If he be 
given a red star, he must find another red star and 

* See photographs of models in use at Sandlebridge (p. 228). 




1 m 

m 



SENSE ROOM 229 

bring it to the teacher and fit it into the star-shaped 
hole in the piece of wood from which it was cut. 

There seems to be a great advantage in having all 
these models made of a size that readily attracts the 
child's attention and makes them easy to grasp. 

The cupboard for smell contains a variety of sub- 
stances such as pepper, mustard, onions, lavender, put 
into bottles with wide necks, which can be easily offered 
to the child's nostrils. He is blindfolded and has to 
guess what is offered to him. The taste cupboard has 
a number of bottles with different strong-tasting sub- 
stances in them. The bottles must be wide enough to 
allow of a spoon being inserted. A basin with water 
and some harmless disinfectant is at hand to wash the 
spoon after each use of it. The teacher gives the child 
a tiny taste, say, of ginger or of flour or of salt or any 
other substance of which it may be supposed to know 
the name; always she finishes up with a little taste of 
sugar. And always, after each use of the spoon, she 
dips it in the basin and wipes it on a clean cloth. The 
child is, as before, blindfolded. 

The hearing cupboard is furnished with a variety of 
instruments for making different noises. Bells of various 
sizes, cymbals, rattles, whistles, etc. The child guesses, 
blindfold, which instrument is being used. 

The touch cupboard has a big bag, full of all manner 
of objects ; balls rough and smooth, pot eggs, little 
dolls and toy animals, bricks, pieces of cloth, woollen, 
cotton, and silk. The child dips into the bag and 
guesses without looking what object he has laid hold of. 

A clever teacher will make this lesson as delightful 
as a game to the children, and will constantly vary the 
objects used. 

Around the room are the elementary forms of kinder- 
garten work. They are, more or less, in use in all 
infant schools, and need not be specially described. 
One item which I have not seen elsewhere was the 



230 APPENDIX I 

strands of red and yellow and blue cloth, hanging from 
hooks on the wall, ready for plaiting by the children 
as they stood in front of them. They have to reach 
up a very little to get at them, and the attitude is a 
good one for the feebleminded, whose inclination is too 
often to look down and hang the head. 

It would be superfluous to enter into all the details 
of the routine of a school for the feebleminded.* They 
are very well known to every one who has had to do 
with such a school. Generally it is safe to say that 
the methods employed should be those of the kinder- 
garten, but that these should be so adapted as to teach 
the child not only co-ordination of hand and eye, and 
as far as possible to develop its reasoning powers, but 
to teach it at the same time to perform some useful 
work. A child has learned a great deal when it has 
learned to lace its own boots. This is an excellent 
lesson for hand and eye; but it is also something 
accomplished towards the after-care of itself. A child 
has had a lesson in training of hand and eye when he 
has learned to weave paper into patterns ; but he has 
not thereby achieved anything of lasting value. He 
will still have to learn to lace his boots. There is much 
training in the knitting of stockings, training in count- 
ing, in the use of the fingers and in memory and 
observation. It is a far better occupation for the child 
than the mere knitting up of a quantity of wool, which 
is afterwards unravelled and given to another child to 
knit again. Very few feebleminded children are in- 
capable of perceiving that they have been employed on 
a useless piece of work. It is most desirable that every- 
thing the child is taught by way of occupation should 
serve some useful purpose. Knitting, sewing, rug- 
making, Macrame work all are admirable exercises, and 

* See circular issued by Board of Control : — " Suggestions for 
School Organisation, Classification in Institutions for the Mentally 
Defective." 



TEACHING 231 

are at the same time an asset in the child's after life. 
No skilful teacher will follow this principle to excess. 
There are exercises which must be used merely for their 
present value, or for the pleasure which they give to the 
child, such as arranging coloured pegs in holes or 
putting together a dissected puzzle. In the main, how- 
ever, it is well to remember that the defective child can 
acquire only a limited amount of knowledge, and that 
with much pains and patient labour on the part of the 
teacher. This painstaking labour may as well be 
bestowed on what will make for future efficiency, seeing 
how short is the time during which we can hope to teach 
the child anything. 

Some children in every school will be able to learn 
to read and write. Very few will care so much for read- 
ing that they will take pleasure in it after they have 
left the school-room. Every boy and girl ought to have 
the chance. One little girl who is excessively trouble- 
some can always be kept quite good and happy by 
giving her something to read which she has not read 
before. As to writing, I confess to being sceptical as to 
its value. In at least one great institution, the know- 
ledge of how to write has led to great difficulties in 
managing the high-grade cases, the men and women 
communicating with each other by means of notes. 
Simple arithmetic has a practical value which makes it 
a very useful subject to be taught. It is interesting to 
note that the children themselves, by their games, teach 
each other a good deal of simple reckoning : they count 
the number of times they clear the skipping-rope, the 
number of times they catch the ball, they reckon whose 
turn comes next. 

In the same way they deal with one of the greatest 
problems that the teacher of defective children has to 
face, the problem of defective speech. Children who are 
constantly together will communicate with each other, 
and many a child who comes to Sandlebridge with 



232 APPENDIX I 

scarcely any vocabulary learns from his little school- 
mates far more than he can be taught in the school- 
room. Nevertheless, this is one of the most significant 
defects with which the teacher has to deal. It is worth 
while to take much trouble to improve a child's speech 
and to give him more words. If pains be taken with 
the enunciation in the singing lesson, this is a great help 
towards the improvement of speech. At prayers also 
the children should be taught to try to say the words 
they are using distinctly and slowly. Here again, as in 
all concerted action, they learn from each other. It has 
been contended that children of weak intellect should 
be treated singly, a teacher devoting to each a great 
deal of individual attention. This is a great mistake; 
and it is here that the children of the poor often have 
an advantage over the children of the rich. They have 
all the gain there is in companionship. All children 
delight in concerted action, and especially does the 
defective child find pleasure and profit in it. For him 
it is particularly necessary; normal children have all 
some points in common, however much they may, on 
the whole, differ from each other; the defective child 
is, by reason of his defect, more isolated; there are no 
two defective children who are alike in tastes, abilities, 
and habits. If once the boy or girl can be induced to 
take part in organised games, drill, marching or singing, 
the spirit of rivalry, the desire to do a little better than 
his neighbours, may be aroused; then there is hope of 
progress. 

Lessons of any kind, whether for head or hand, must 
not be made too long. Change is wholesome, and a 
wise teacher will see that her little scholars are not kept 
too long in one position or at one kind of work. In 
short, all that is of use in a well managed infant school 
is of use in a school for the feebleminded. 

It will not unfrequently be found that the brighter 
children, those who are capable of learning to some 



SCHOOL 233 

extent, have a great dislike of it. This is probably 
because these children have a greater degree of physical 
strength than the worse cases. They are often robust, 
rough children with much animal vivacity, which it is 
very difficult to control. It is well to take the earliest 
opportunity of releasing such a child from school and 
sending him to more congenial work. I say the earliest 
possible, because the children must be occupied and care 
must be taken not to allow a young boy to do too much 
physical work. School is a great safeguard against 
over-work. These children to whom lessons are irk- 
some and who therefore give endless trouble to their 
mistress, will often become quite manageable when put 
to work under a man out of doors. No doubt the fact 
that the man's greater strength enables him to control 
the naughty boy without a struggle has something to 
do with the matter. Especially is this the case with chil- 
dren of violent temper. C. A., aged twelve, was a short, 
thick-set, sturdy boy, very strong. He was quite able to 
read and write, but detested doing his school work. He 
was subject to storms of uncontrollable passion during 
which he was blind and deaf to all remonstrance. After 
one such attack, during which he had thrown his dinner 
at the wall, he was sent to work as a means of checking 
the terrible sobbing with which his attacks always 
ended. In five minutes he was quite happy, unloading 
coal with one of the older boys. He was then given 
for half of each day to the horse-man, the understand- 
ing being that if he were naughty in school he could 
not go to work. The plan answered admirably, and 
for over a year now he has not gone to school at all; 
he is about fourteen years of age ; still very small, but 
very strong. He can harness the horses, who put their 
heads down to him since he cannot reach up to them. 
He is now milking five cows morning and night, is a 
most useful farm-boy, and as happy as the day is long. 
The other child was endlessly troublesome and dis- 



234 APPENDIX I 

obedient; fretful and teasing and mischievous to the 
last degree. He was always in disgrace. He also 
could read and write. At last, though he was full 
young for it, we tried the same experiment with him as 
with the other boy. We sent him to the gardens. He 
has wonderfully improved, is happy and generally good, 
and seems much better in health; he is round and 
rosy-faced with a nice bright grin instead of the down- 
cast scowl he used to wear. It would be well if his little 
sister could be treated in the same way. 

It is, of course, necessary that one should be able to 
trust the men to whom one hands over such children; 
they should be good-tempered and patient and willing 
to teach; careful also that the children do not get 
over-fatigued or wet and cold. 

The great advantage of a residential school over a 
day school (so long as school life goes on) is that every- 
body concerned with the children teaches them. 
Matrons, house servants, gardeners, farm-men — all 
must be selected with a view to their being able and 
willing to assist in the training of the children. It is 
a work demanding endless patience and sympathy. But 
it is one that has a growing fascination for those who 
embark upon it whole-heartedly and unselfishly. 

Work. — There cannot, with propriety, be fixed any 
age at which the children of a colony should quit the 
school-room and go to work. As has been seen, there 
are cases in which it is desirable to allow the child to 
leave the daily routine of lessons exceptionally early. 
If school work is an excellent means of providing train- 
ing and employment for children without undue physical 
fatigue, work outside the school-room, physical labour, 
is an equally good means of occupying and training 
those who are troublesome and robust. In every case, 
the individual character and needs of the child must 
be considered. When it has been decided that a boy 
or girl shall go to work, it is well to secure in the first 



WORK 235 

place that the mere fact of this promotion shall be 
regarded as a favour. This is not difficult to manage. 
When the preliminaries have been arranged the ques- 
tion should be raised in the presence of the child. It 
should be quietly discussed whether the child is good 
enough to be allowed to work ; whether he or she can 
be trusted not to give too much trouble. Then the 
matter can be held over for a little while, expressly for 
the purpose, from the child's point of view, of consider- 
ing these weighty matters. During this period those in 
authority will be besieged by requests to be allowed to 
go out and work or, if it be a girl that is under con- 
sideration, to be allowed to go to the laundry. When 
the time finally comes for the child to be released from 
lessons, a pleasant fuss should be made about the 
matter. There will be the necessity, probably, for 
making some suitable change in the clothing worn; 
of getting up a little earlier and going to bed a little 
later; of being big instead of little. All these things 
should be conceded as a great favour. Almost any 
work that is within the physical and mental capacity 
of the children can he got from them by allowing them 
to do it as a favour instead of imposing it as a duty. 
The question of duty must not be neglected, but 
it will have to come by degrees. The first thing to do 
is to make them see the truth that it is a privilege to 
work. 

Then comes the question of making sure that the 
child shall not be disheartened at the beginning by 
being given a task that is beyond his or her strength. 
For instance, if a boy be about to learn to dig, it is 
well at first to give him a spade that is only three- 
quarters of the usual size. He will be able to handle 
this with ease. From the outset care must be taken 
that he does handle it to some purpose. He must not 
be allowed to play with it; the spit of earth must be 
properly dug and completely turned over and the 



236 APPENDIX I 

digging, however slowly, must be done. It must be 
remembered that an ounce of encouragement to these 
children is worth a pound of blame. I have in my 
mind a big, lazy, good-natured girl, who for some time 
after leaving the school-room seemed hopeless as a 
worker. One day it was noticed that she was turning 
the handle of the mangle. It was purely mechanical, 
but some one remarked with much expression of sur- 
prise and pleasure : — " How beautifully N. does turn 
the mangle. I should not wonder if she could fold 
pillow-cases just as well." Of course N. wanted to try, 
and was delighted to find that she met with a measure 
of success ; after a few weeks of patient teaching N. 
could fold clothes. Now the once helpless, feeble fingers 
can do much more than that; she can iron clothes. 
Girls, even more than boys, need to be watched that 
they do no more than is good for them. It is to be 
hoped that, wherever funds admit of it, variety of 
occupation may be provided for all girls. Weaving, 
mat-making, lace-making, all are possible and all are 
profitable and pleasant for the children. This greater 
delicacy of the growing-up girls is no doubt one reason 
why they are more difficult to manage than boys. If 
a boy is troublesome it is in most cases safe to let him 
work his naughtiness off. With the big girls, however, 
the demonstrations of hysterical temper that often 
occur, between the ages of thirteen and eighteen have 
to be considered as indications for extra care. Indeed 
they are often accompanied by definite illness. For 
instance, one girl for some years had a distinct rise of 
temperature once a month; this was always observable 
when she was particularly naughty and bad-tempered. 

The physical strength of the feebleminded is generally 
as defective as is their mental strength, though, of 
course, there are notable exceptions to this rule. The 
lack of co-ordination between hand and eye makes the 
using of their muscles a greater fatigue to them than 



WORK 237 

it is to ordinary children. Their clumsiness increases 
their labour. If due care be taken, when they begin 
to work, that they are not over-fatigued, a marked 
improvement in health and strength generally shows 
itself after the first six months of bodily work. Their 
muscles develop and they gain more skill in the use of 
them. Their knowledge increases and their horizon 
enlarges. They learn to know something of the pro- 
perties of matter; they begin to understand that 
earth is soft and stones are hard and heavy in propor- 
tion to their size. Many of them have previously been 
in the position of the little child who was seen one day 
patiently trying to fit the front door key into the lock 
of his mother's bureau. Now they learn from practical 
experience about the relative sizes of things ; about 
angles, squares, and other geometrical figures. Not 
that they can call them by their names, nor is it of 
importance that they should do so; the point is that 
they should no longer make errors in their daily work 
from the lack of perception of the shapes of things. 
Rough and smooth begin to have meanings for them; 
the boy knows that the mowing machine will make the 
lawn smooth, the girl that the hot iron will do the same 
good office for her pinafore. Cause and consequence 
take part in their daily routine of thought : the cows 
must be fed that they may give us milk, the chickens 
that they may lay eggs. Potatoes must be peeled 
because the peel is nasty and bad to eat. Weeds must 
be taken up because they will kill the flowers. 

The men and women who have charge of the children 
during their working hours should be carefully chosen 
because of their power of understanding the condition 
of the boys and girls, and their ability and willingness 
to make all work a continuation of education. It goes 
without saying that self-control and patience are 
absolutely essential for these out-of-door teachers. 

For some of the children it will be found necessary 



238 APPENDIX I 

to give them change of occupation from time to time. 
For most the best plan will be to get them into a groove 
and keep them there. If a garden boy wants to leave 
his work and go to the farm, if a laundry girl wishes to 
forsake the laundry and take to sewing, care should 
be taken to ascertain whether there is any more in the 
wish than the restless desire for change. Time is lost 
in getting the children into the habits of one class of 
work and then allowing them to throw it over and 
begin upon another job that entails fresh teaching and 
learning. Sometimes, however, especially if the child 
has got into a fractious cross fashion with those who are 
over him or working with him, it will be well to give 
the change. For some of the low-grade cases no change 
is ever desirable nor is it wished for. One must be very 
glad if a boy or girl can learn to achieve successfully 
some small mechanical piece of work, such as washing 
flower pots or polishing a floor. At least that piece of 
work need not be done by a child of greater intellect. 

In considering the work of the feebleminded two 
matters have to be kept constantly in view; the first 
is the welfare of the boy or girl, the second the money 
result that may be obtained from their labour. 

It is essential that the weak in mind should be 
employed in order that they may be as healthy as their 
bodily limitations will permit; it is essential also that 
their employment shall be so regulated and thought 
out as to make them happy in it. 

It is also essential that the work they do shall not be 
wasted effort, but shall either bring in or save money. 
In the case of the very best of the feebleminded, it is 
probable that the difference between their earnings and 
those of the normal boy or girl of the same age will 
be represented by the cost of their supervision. Some 
boys and girls will do surprisingly good work when 
looked after; others will be able to achieve very little. 
The object to be aimed at is that no boy or girl or man 



GAMES 239 

or woman who is able-bodied shall be allowed to do 
nothing. Idleness means degradation of the lowest kind 
for the feeble in intellect. There is no other way but 
regular work, which leaves the children so tired at night 
that they go to sleep when they go to bed, to keep 
them from falling into habits which further lower the 
already low intelligence and physical strength. 

Games, — The more the children play, the better. 
Organised games are good. In England football and in 
America baseball are great stand-byes. Great value, 
however, is to be attached to games that the children 
devise for themselves. They should be given chances 
to play freely and follow out their own plans. Where 
possible a piece of ground in which they can grub round 
without doing themselves or other people any harm is 
a great advantage. It is pleasant to see little gardens 
growing up in corners of the playground. It may be 
sad that they should be the sort of gardens which belong 
to a much younger age normally, but it is so good that 
they are there at all. Skipping, ball games, hoops, 
kite-flying all are good. Horses, with reins made from 
any ends of strings that the children can find, are 
excellent. Such reins are far better than the pretty 
ready-made ones that are given so kindly at Xmas-tide. 
It is better for the child to be prompted by his desire 
to play horses to look for or beg string and then to 
knot it together himself, than to have all his wants 
supplied. Often it is a pleasure to the children to carry 
out in play-time what they have learned in school. 
Some girls at Sandlebridge picked up every stray bit of 
wool that they could find or beg and made these into 
a pair of bedroom slippers for their matron, without 
help from anyone. They saved their pennies and bought 
the soles and stitched them in. The result was curious 
to look at, but the slippers were properly made in every 
particular. 

I have found children knitting with bits of ravellings 



240 APPENDIX I 

and smoothed pieces of twig which they had broken 
from the hedge. In their games especially the delight 
of the feebleminded child in accomplishing something is 
apparent. It ought to be encouraged to the utmost 
degree. 

Like other children, these boys and girls enjoy make- 
believe ; they like to play at shop or at school. One very 
unsocial child would, so soon as school was over, take 
a number of stones, range them in a line, and proceed 
to give them lessons; this one she would praise, the 
other blame, mimicking the routine of the class she had 
just left. She much preferred this to playing with the 
other children. This unsocial disposition is not to be 
encouraged. The children must learn to take their 
share of rough and smooth in the little community of 
which they form a part. They educate each other in 
their play quite as much as their teachers can educate 
them. Needless to say, they must not be left to play 
unsupervised. Someone must be at hand to interfere 
if passions, always too readily roused, become uncon- 
trollable. For games in the house building with bricks, 
dolls, dissected picture puzzles, skipping and dancing 
are all good. Soldiers are an endless delight to boys. 
Toys are broken very frequently; they must not for 
that reason be put out of the children's way. It is 
better for them to break their toys than for them not 
to play. These indoor games afford the opportunity of 
enforcing lessons in tidiness and order. The children 
should learn to put away the things with which they 
have been amusing themselves. Care, however, must 
be taken that too much is not sacrificed to tidiness. 
It is not possible that a large room, in which a number 
of children have for some time been playing happily, 
should look tidy. 

Hospital or Sick and Isolation Rooms. — It is essential 
that in every colony there should be the means of com- 
pletely isolating a case, if the doctor desires to do so. 



SICK ROOM 241 

All doubtful cases of illness should be isolated pending 
his decision. A hospital is, of course, much the best, 
but if this cannot be had, rooms should be arranged 
in which the children can be nursed if they are ill. One 
room of four beds to every forty children will probably 
suffice. There should be no furniture in these rooms 
except the beds. A nurse can easily carry in a little 
table and a chair if she needs them. When the child 
gets up, one of the small tables and chairs provided for 
the living rooms can be taken in for it. The room should 
face South, and should be easy to warm and to ventilate. 
There should be an open fire in it, well guarded. The 
walls should be light in colour and easy to clean. A 
bright linoleum should cover the floor. The ordinary 
appliances for the use of sick people should be at hand ; 
it is useful to have, for those children who are not very 
ill, a white china pail to save them from going to the 
office to relieve themselves. This shews when it is 
soiled, and can be easily cleansed. It will be found 
that, as a rule, feebleminded children are much more 
content to lie in bed than are ordinary children. It is 
not good for boys to lie in bed, and so soon as the doctor 
permits a sick boy should be allowed to sit up. A boy 
should not be sent to bed for slight ailments, nor should 
he be sent to bed as a punishment. For a girl, a day 
in bed is often a very good thing; the comparative 
isolation and complete rest are often the best cure for 
attacks of nervousness or temper. 

The sick-room window, and all other windows above 
the ground floor, should be protected so that children 
cannot climb out of them. 

Every care must be taken to provide easy exits in 
case of fire. 

Dispensary. — This will be under the charge of a nurse, 

and should contain such things as are likely to be used 

or dispensed by the doctor at his weekly visit. It is 

mentioned here chiefly to insist on the necessity of its 

Q 



242 APPENDIX I 

being kept carefully locked, and of the poisons being 
separated from other drugs. 

General, — It will be seen that there is no hard and fast 
line which can be drawn dividing the childhood of the 
feebleminded from their manhood — their school-life 
from their industrial life. It is necessary when the 
child comes into our care to let him become part of the 
community in which there is a natural linking-up be- 
tween all the stages of his growth, dependent in every 
case upon his individuality and not upon his age, until, 
indeed, he reaches the point at which, for obvious 
reasons, it is necessary to separate him at night from 
the younger boys. Even this cannot be a fixed point. 
It is sometimes desirable to keep a childish boy longer 
with the younger ones, or to remove a precocious youth 
sooner from their company. Even when the big boys 
and girls are sent to sleep apart from the children, it is 
well that they should still take their meals under the 
eye of the matron of their house, so that a watch may 
be kept upon their manners and their habits of eating. 

In every case what should be aimed at is to find out 
what it is in the feebleminded child that is normal and 
to develop that so far as possible. Dr. Lapage has 
defined feebleness of mind as irregular failure of develop- 
ment. It is because the development is irregular that 
we find such startling incongruities in their behaviour. 
It is sometimes difficult to realise that their absurd and 
inconvenient actions are not wilful, when they have 
been seen to behave quite like normal beings in other 
matters. The more like normal beings they are treated, 
the better for them. Within its due restrictions their 
life should be that of normal people. The one thing 
to be remembered is that even the best of them cannot 
be counted on, and that, while we try to make them feel 
responsible, we must always remember that they are not 
responsible. Kindly encouragement and strict super- 
vision must be the key-notes of their training. Absolute 



SANDLEBRIDGE COLONY 243 

division of the sexes must be maintained except for 
little children at lessons. 

All who work with the feebleminded must be chosen 
with a strict regard to their characters, and especially 
with a view to their self-control and patience. It should 
be carefully explained to them, when they are engaged, 
what are the difficulties to be faced, and they must 
be men and women who can be absolutely trusted to 
take care that the boys and girls shall hear nothing 
harmful. Especially it should be explained to them 
that they must not talk to the children about the out- 
side world. The effort of everybody concerned ought 
to be to make the world in which the children live so 
very interesting to them that they will not want to 
leave it. This can be done. The child remains a child, 
whatever his age may be, he has a child's outlook, a 
child's pleasures and expectations. It rests with those 
responsible for him to decide whether he shall be a 
happy, good, pure child, or a plague-spot upon the face 
of the earth. 



SANDLEBRIDGE COLONY FOR THE FEEBLE- 
MINDED. 

Sandlebridge Colony is the outcome of the work of 
the Lancashire and Cheshire Society for the Permanent 
Care of the Feebleminded. This Society was founded 
in 1898. The somewhat clumsy name of the Society 
is due to the fact that it was determined from the 
beginning to adopt the principle that only Permanent 
Care could be really efficacious in stemming the great 
evil of feebleness of the mind in our country. The idea 
at first met with much opposition; no other Society 
was willing to entertain it, and it was obvious that it 
would take much work and some time to accustom 
people to it. Happily it is now universally regarded 



244 APPENDIX I 

as the proper method of dealing with the weak in 
intellect. 

The first step was to convince people that the work 
we had pledged ourselves to was worth doing ; and the 
second to collect funds with which to do it. Here the 
assistance and countenance of the late Mr Herbert 
Philips was invaluable. The David Lewis Trustees, of 
whom he was one, were asked for help and gave twenty 
acres of land, which Mr Ben Levy most kindly selected 
and personally presented to the Society. 

The Society owns some two hundred acres. The 
first house was opened in August, 1902. There are now 
on the estate, which is situated in pleasant country at 
Great Warford, about three miles from Alderley Edge, 
six residential houses, a day school conducted under 
the regulations of the Board of Education, a hospital 
erected to the memory of the late Dr. Ashby, farm- 
houses and cottages, as well as a good laundry. The 
colony is lighted throughout by electricity generated on 
the premises. There are 170 boys and 116 girls in resi- 
dence of all ages from five to thirty; 182 are over the 
age of sixteen. In addition to the homes for children 
there are two homes for adult men, Manor House and 
Brook House, and a house for adult women at Warford 
Hall. The institution is carried on under the certifi- 
cates of the Board of Education and of the Board of 
Control. The recognised accommodation is for 200 
and 295 respectively. A range of workshops costing 
some £5,000 is in course of erection, and it is hoped 
when materials become less expensive to provide a recrea- 
tion room, as well as to improve some of the farm 
buildings, and possibly also to extend the accommoda- 
tion generally. The inmates are classified according to 
their age and sex. Little boys, 90 in number, are in one 
house, boys from twelve to sixteen in the " Boys' 
House." Boys from sixteen to twenty-two are at Nor- 
bury Farm to sleep, but return to Manor House for 




<Ms£ /sHfe! 



SANDLEBRIDGE COLONY 245 

meals, prayers, baths, etc. In this way a hold is kept 
upon their manners and behaviour. A generous friend 
gave the money to provide Brook House Home, and 
in this boys over twenty years of age are accommodated. 

Girls are, at present, divided into two groups — the 
little girls in the (i Girls' House " and the older girls 
at Warford Hall. Further accommodation for girls is 
urgently needed. 

The results of the principles upon which the colony 
is managed have been very happy. All the children are 
fully occupied from the day of their entering the school ; 
even very little ones are trained to look after their own 
persons. The grown-up children justify the way in 
which they have been trained. They are very con- 
tented, and do a good deal of useful work, thus 
contributing to their own maintenance. A special 
instructional class has been opened for certain low- 
grade boys, impossible to otherwise occupy suitably, 
and good results have been obtained. The grown-up 
boys are mainly employed on the farm and in the 
gardens and in the shoemakers', carpenters,' and 
plumbers' shops, and some of the more delicate ones are 
occupied as house boys. There are over eighty head of 
cattle as well as pigs, poultry, etc., and the boys, always 
of course under strict supervision, help very efficiently 
in milking and in the general work of the farm. 

The girls over school age are engaged in house and 
laundry work, sewing, knitting, etc., and it is hoped to 
considerably extend the scope of their occupations as 
well as the occupations of the boys when the new work- 
shops are provided. 

The management of the farm has passed from the 
hands of the late Mr C. H. Wyatt, who, as a member 
of the governing body, had always taken a keen interest 
in the work at Sandlebridge, to those of his son, Mr 
C. H. Wyatt, who is also a member of the governing 
body, and has by his untiring efforts done a great deal 



246 APPENDIX II 

to make the farm a success. Ten men are employed 
on the farm and gardens, and they guide the labours of 
those feebleminded who are able to do work on the land. 

The domestic control of the institution is in the hands 
of a Lady Superintendent, helped by an adequate staff 
of assistants. A plumber and carpenter are resident, 
and attend to the necessary repairs and to the electric 
lighting installations and also act as attendants. Each 
house has its own Master or Matron, and there is a full 
teaching staff in the day school according to the regu- 
lations of the Board of Education. 

The Society is Incorporated and is managed by a 
Governing Body under the Chairmanship of Sir Thomas 
Thornhill Shann. A House Committee meets once a 
month at the colony. 

The Hon. Secretary is Mr James S. Walker, and the 
Medical Officer, Dr. James Mcllraith, of Alderley Edge. 

All cases of sickness, except infectious ones, are 
treated in the Ashby Memorial Hospital, where there 
is a trained nurse in residence. A full dental equip- 
ment has been provided at the hospital, and Mr 
Mackenzie, of Wilmslow, attends when necessary. In 
addition the services of consulting eye and ear surgeons 
are available. 

Applications for admission should be made to Mr 
E. M. Richards, General Secretary of the Society, 
1 Brazennose Street, Manchester, from whom all infor- 
mation may be obtained. 



APPENDIX II 

THE DETAILED EXAMINATION OF THE HEAD 

Methods. — Before commencing a detailed examination of the 
head measurements the observer should make himself familiar 
with certain of the external markings of the skull. 



THE SKULL 247 

The most important of these for the purpose in hand are : — 

(1) The tragus or point just in front of the opening of the ear. 

(2) The external occipital protuberance, a projection in the 
middle line at the back of the head just where the skull 
joins the neck. 

(3) The external angular process of the frontal bone at the 
outer angle of the orbit. 

The skull is made up of eight bones and the roof is formed by 
four, viz., the frontal bone in front, the occipital bone behind, 
and the two parietal bones on either side. 

The measurement most commonly taken and the one which 
suffices for ordinary purposes is the greatest circumference of the 
head taken in inches or centimetres with a tape (not a metal) 
measure, but if it is desired to examine the head more thoroughly 
the following special measurements are of value : — 

(1) The contour tracing of the greatest circumference, taken by 
moulding a strip of lead* to the head and checking the diameter 
with callipers. 

The contour of the bitragal arc or the arc of the skull as 
measured from ear to ear. 

(3) The contour of the naso-occipital arc or the arc of the skull 
as measured from the root of the nose to the external occipital 
protuberance. This tracing gives the slope of the forehead and 
the occipital development. 

(4) The height of the skull can now be measured by marking 
in the base of the bitragal tracing and dropping a perpendicular 
line on to the base from the arc at a point which is at equal 
distances from the two tragal marks. The length of this vertical 
line will represent the comparative height of the skull. Though 
this method may not give such an accurate measurement of the 
height as the one advocated by Mackenzie, it is sufficiently accu- 
rate for the purposes of comparison. 

(5) The antero-posterior and bilateral diameters have already 
been taken. It is much more convenient to use self-recording 
callipers which have a scale marked in both inches and centi- 
metres. 

A detailed examination of the heads of feebleminded children 
is of value as illustrating the following points : — 

(1) To obtain a general idea of the size of the organ contained 

in the skull as accurately as is possible by external measurements. 

- (2) To see whether there is any diminution in size of the skull, 

* Lead suitable for taking these contours can be obtained from instrument 
makers, and callipers should be marked with a scale in both inches and centi- 
metres. A detailed description of how to take these measurements can be 
found in the " Medical Chronicle " of August, 1905, and in " The Medical 
Inspection of School Children " by Mackenzie, Edinburgh, 1904. 



248 APPENDIX II 

and, if such be present, to determine whether it is due to defect 
of any one region or merely to a general under-development. 

(3) To find whether asymmetry or irregularity is to be noted 
in a large number of cases. 

(4) To discover if there is any relation between the deformity 
and the nature or degree of the mental deficiency. 

Results. — The following table shows a comparison of the heads 
of four different groups of twenty feebleminded children, and 
twenty children taken at random from the wards of a hospital, 
i.e., one hundred children in all. The classification into " Good " 
and " Bad " refers to the mental capacity, which was in each 
case estimated independently by the teacher. In order that the 
table might be as fair as possible, the cases in each class were 
taken at random from the 200 cases examined before any refer- 
ence had been made to the head measurements. In Column 1 
the heading " Occipital greater than Frontal by Total of," repre- 
sents the sum total in inches of the differences between the 
occipital and frontal radii (see Plate III.) in the cases in which 
the occipital radius was longer than the frontal. The headings 
of Columns 2, 4, and 5 are explained in the same way. Columns 
3 and 6 show the number of cases in which the radii were equal. 
Column 7 shows the estimation of the general appearance, G. 
standing for good, F. for fair, P. for poor, and B. for bad. The 
last column gives in cubic centimetres the figures obtained by 
multiplying the length, breadth, and height together. This, 
though not representing the true cranial capacity, gives some 
approximate idea of the size of the brain. 

Smallness of the maximum circumference is common in the 
feebleminded; 34 per cent, of my cases had small heads if a 
head below 20 inches in circumference is to be regarded as small. 
Asymmetry, as brought out by the contour tracings, is also very 
common indeed. Marked asymmetry occurred in 25.9 per cent, 
of my cases and a lesser degree in many more. The right half 
of the skull as measured by the above methods is often greater 
than the left. The degree of inequality is estimated by taking 
the difference between the two parts of the bilateral diameter as 
divided by the line of the antero-posterior diameter (see Plate 
III.). In by far the majority of cases the right side was greater 
than the left, sometimes by as much as 1£ inches. This asymmetry 
is compared in Table V., and it will be seen to occur with much 
greater frequency in the feebleminded as contrasted with the 
children of ordinary intelligence. 

Since children who showed the most marked stigmata of 
degeneration exhibited this lateral asymmetry to the greatest 
degree, it should be regarded as a stigma of degeneration. 



THE SKULL 



249 



£2. 









6 fo (^ pq d fe cu 

»fl)^H ® fc- fc- 



*"* CO fr- 



>"H C© CN i-< 



IT5 CO CO CO 





*ia 


.2 


.5 


d 








d 




5*1 










1 








H<n 


H* 


H« 




1 




H* 




£ aH 


(N 












T-H 








































•^■< j, o 


















■~ 4-4 

5^| 


.s 


d 


.2 




.2 




d 








<* 


CO 




CD 




CO 


> 


s * 
















^ 


13 
















H-J 


pi 


CO 


GO 




<N 




CO 




a 1 
















H 


tal 

than 

al of 


d 


1 


.5 




d 




d 




a m-^^ 




1 














o3 ° ° 


H« 




H« 




H« 

i— i 




I-l 




H >> 


















O -Q 


















-ho! 'g 




















d 


.s 


d 




d 




.S 




8l2^ 


H* 


HM 


•« 




•i-i 




-i-» 




CO 




He* 




•*0 




CD 




o^^ 


i— < 


rl 


"5 




** 








cs A3 




















«W 1 


-T3" 


'S- 


'Cd . 


TJpCJ ■ 






O 


CDrQ 


QJ" 


CD 


flj • 


a> 


8 








T3 O 


n3^3 


T3J* 


T3 








fl o 


fl as 


G 


H 


c 


CD 






a ■ 


1» 


1? 


112 


I 


to ' 






Is 


cd cs 




CO 

1 


sl 


1 


bO 

•S ' 






o S 


(0 


*_ 


.5° 


•rt -m 


<v 


'•4^> 






# b0 


4) 




<w 




«w 


3 






§<2 


o w 




©.a s 


o 


S ■ 










CM 


B'-8 


CM 


CO 






o © 

bo 


w cd 


w cd 
u 


M-H 
O 


2 g 


O 


i-g 






B> 2 


• 2 


»2 


Cfi 


H3 


m 


2 » 






T3 CD 


■-a -2 


ns ~ 


■"O 


72^3 


nO 


S «45 






es > 


« ^3 


cS J3 


C3rfl C 


eS 


^3 CJ 






CD CS 


CD u 


0) CJ 


CD 


O cS 


<U 


CJ H3 






w 


ffi 


ffi 


ffi 




n 





250 APPENDIX III 

Another abnormality frequently shown by the tracings was 
deficiency of the posterior parts of the skull as compared with 
the anterior, the bilateral diameter being taken as dividing the 
skull into these two parts. The table shows this abnormality to 
become more and more marked as we progress from " Good " 
cases to " Bad " cases, and deficient occipital development is one 
of the most common deformities in the skull of a feebleminded 
child. Ashby and Shuttleworth both describe this abnormality. 

Taking the normal heads as a standard, the measurements from 
the point at which the diameters cross to the two ends of the 
antero-posterior diameter should show that the posterior division 
is f inch to 1 inch longer than the anterior (Plate III.). In 
many of my cases there was marked deficiency of the posterior 
division of the skull as compared to the anterior part, and this 
fact points to the frequent occurrence of under-development of 
the posterior division of the skull. A diminution of the curve of 
the occipital bone was also shown by the naso-occipital tracing. 
(Plate III.) 

Abnormalities of the frontal region were chiefly in the form 
of a general rounding when looked at from above, or under- 
development as shown by the lateral view. 

The tracings of the bitragal arc often showed asymmetries and 
irregularities in the skull conformation, but no one abnormality 
is especially common. 

It should once more be stated that these measurements refer 
to the skull and not necessarily to the brain. 



APPENDIX III 

THE DETAILED EXAMINATION OF THE SPEECH 

Method of Testing. — The following is the best method of test- 
ing and analysing the defects of speech in feebleminded children. 

Attach 20 or 30 cards loosely together on string and devote 
one card to each consonant. The consonants and the physio- 
logical alphabet are given in Chapter V. Each card should 
have the description of the consonant at the top, and beneath 
that should be written words containing the consonant in its 
three positions, i.e., at the beginning, at the end, -and in the 
middle of a word. It is better to have several common words 
as alternatives, because many simple words are not known to a 
feebleminded child. Drawings or colours must be definite in 
character, and it is better to have each drawing on a separate 
card. 



SPEECH 



251 



The following is a reduced facsimile of the card used for P : — 

P. LABIAL 1st Stop. 
Voiceless Oral. 

(1) Pen— Paper. 

(2) Soap— Sheep— Top. 

(3) Paper. 

The words must be chosen with regard to the ease with which 
they can be represented and understood by the child. 

Numerals, colours, and any objects, commonly found in the 
room, will be found to be very useful, while all that is needed 
in addition to these are a few drawings and one or two small 
articles. Phrases such as " Silly Sarah," " Large rat," " Red 
lamp," may be used as additional tests in the better class of 
case, but they are open to objection because they have to be 
pronounced first by the person conducting the examination. 

It is not possible to test H or Zh, and some consonants only 
occur at one or two of the three positions. Combinations of the 
consonants are more difficult to test, and also more frequently 
pronounced badly, but the defect is frequently traceable to im- 
perfect pronunciation of one of the two. 



The following table 
consonant : — 



P. (1) Pen, paper. 

B. (1) Button, book, 

bag. 
M. (1) Mouth, match, 

man. 
W. (1) Wood, window. 
F. (1) Fish, five, fire. 

V. (1) Velvet, violet. 

Thl (1) Thumb. 

thimble, 

thank. 
Th2 (1) The, that, this. 
S. (1) Soap, six, 

scissors 



TABLE VI 

shows the words used for each testing 

(2) Soap, top, pipe, (3) Paper. 

cap. 
(2) Crab, tub, rub. (3) Rabbit. 



(2) Jam, thumb. 

(2)- 

(2) Roof, cough, 

laugh. 
(2) Glove, five, 

sleeve 
(2) Mouth, teeth. 



(2) Bathe. 
(2) Face, mouse, 
glass. 



(3) Hammer, 

mamma. 
(3) Flower. 
(3) Toffee, puffer. 

(3) Seven, eleven. 

(3)- 



(3) Mother. 
(3)- 

[Continned overleaf. 



252 



APPENDIX III 



z. 


(1) — (2) Nose, please. 


(S\ Scissors. 


T. 


(1) Teeth, ten, two. (2) Eight, coat, cat 


. (3) Button. 


D. 


(1) Door, dog. (2) Wood, lad, head. 


(3) Ladder, lady. 


N. 


(1) Nose, nail, nine. (2) One, pen, 
button. 
(1) Shirt, sugar. (2) Fish, wash. 


(3) Penny, raining. 


Sh. 


(3) Washing. 


Zh. 


(1) - (2) - 


(3)- 


L. 


(1) Leg, lad, lead. (2) Ball, wall, nail. 


(3) Collar, yellow. 


R. 


(1) Rabbit, red, (2) Fire, door, ear. 
ring, write. 


(3) Parrot, barrow. 


K. 


(1) Coat, collar, cat. (2) Book, black. 


(3) Pocket, poker. 


G. 


(1) Gun, girl. (2) Clog, dog, leg. 


(3) Sugar. 


Ng 


. (1) — (2) String, tongue. 


(3) Ringing, sing- 


H. 


(1) Head, hair. (2) — 


ing. 
(3)- 


(y) 


(1) Yellow. (2) — 


(3)- 


pi. 


Please. Thr. Three, throw. Sn. Snail. 


Dr. Drink, draw. 


Pr. 


Prince. Tw. Twelve. SI. Sleeve. 


Kl. Clean, clothes. 


Bl. 


Blue, black. Sp. Speak. Sch. School. 


Gl. Glove. 


Br. 


Brown. Sm. Small, smack. Teh. Chair, chin 


Gr. Green. Ft. Fifty 


PI. 


Flower. Sw. Sweet. Tl. Little, kettle. Str. String. 


Fr. 


Frog. St. Stand, stick. Tr. Train. 


Spl. Splash. 



Results. — The following is a list of the consonants most com- 
monly defective, arranged in the order of the frequency with 
which substitution occurred and with the most common substitute 
appended : — 

TABLE VII 

1. Th (Th)— (F) (T). 

2. R-(Y) (L). 
Y-(R) (L). 

4. S— (T) (Ts). 

5. G— (D). 
Ng-(N) (Nd). 

7. Sh— (Tsh) (Ts) (T). 

8. K— (T). 
V-(B). 

9. L-(Y). 

10. F— (T) (P). 

11. Z— (D). 

12. W— (U). 

13. P— (T) (D). 

14. N— (D). 

15. D— (T). 

16. T— (S) or (Ts). 

17. N— 

18. M— 

19. B— 



SPEECH 253 

Cases illustrating speech defect in feebleminded children are as 
follows : — 

T. H., aged 8 years. Hesitates in speech and is much teased 
at school because his speech is defective. Thumb = turn; window 
= indow; wood=uoud; flower =thouerd; fish=tsish; fire = 
tuiere; roof=rootd; fifty =fixy or thissy; vein=beyain; vases 
=barded; sleeve=tuede; five=fide; glove=gud; three= 
tuee; thirty=tirty ; mouth=mouts; that = dat; bathe=bade; 
six=tsix; soap=tchoap; nose = node; toes=tode; shirt = 
tchirt; leg=yeg; read=yead; nail=naid; girl=gir; eleven 
— eyennan; raining =yaining; write=eeyite3 please =puyead; 
fly=cly or fuy; twelve=tyed; little kettle =yuick keka; blue 
=beru; throw =tuo; sleeve =tuyeeve; clothes =cuyede. 

W. M. C.j aged 8 years. Feebleminded; poor power of atten- 
tion; speech bad; P.B.M.W.F.V. good; th=f; scissors = 
sithers; T.D.N, good; sh = th; sheep =theep; sugar =cugar; 
shirt = sirt; fish = fis; watch=watse; L. and R. good; K=t; 
coat = toat ; cat = tat ; G = D ; gun = dun ; green = drean ; 
school = stool; little kettle =»lickle tettle; twenty=bwenty. 

APPENDIX IV 

THE BINET-SIMON TESTS OF MENTAL INTELLIGENCE 

The Binet-Simon Tests were first published in 1906. A revised 
list was published in 1908, and a further revised list in 1911. 
Dr. Goddard published a modified list in 1911. The wording has 
been further modified by the late Dr. Huey and is as follows : — 

Mentality of 1-2 years. — (1) Eye follows light. (2) Block placed 
in hand is grasped and handled. (3) Suspended cylinder 
grasped and seen. (4) Candy chosen instead of block. (5) 
Paper is removed from candy before eating, child having 
seen wrapping. (6) Child executes simple commands and 
imitates simple movements- 

Mentality of 3 years. — (7) Touches nose, eyes, mouth, and pictures 
of them as directed. (8) Repeats easy sentences of six 

syllables with no error. (9) Repeats two numerals. (10) 
Enumerates familiar objects in pictures. (11) Gives family 
name. 

Mentality of 4 years. — (12) Knows own sex. (13) Recognises key, 
knife, penny. (14) Repeats three numerals in order when 
heard once. 15) Tells which is longer of lines differing by 
one centimetre. 

Mentality of 5 years. — (16) Discriminates weights of 3 and 12 



254 APPENDIX IV 

grammes, 6 and 15 grammes. (17) Draws after copy a square 
that can be recognised as such. (18) Repeats : — " His name 
is John, he is a very good boy," and similar sentences. 
(19) Counts four pennies. (20) Rearranges a rectangular card 
that has been cut diagonally into two triangles. 

Mentality of 6 years. — (21) Knows whether it is forenoon or after- 
noon. (22) Defines in terms of use the words, "fork, table, 
chain, horse, mamma," three satisfactorily. (23) Performs 
three commissions given simultaneously. (24) Shows right 

hand and left ear, etc. (25) Distinguishes pretty from dis- 
tinctly ugly or deformed faces in pictures. 

Mentality of 7 years. — (26) Counts 13 pennies. (27) Describes pic- 
tures shown in No. 10. (28) Notes omission of eyes, nose, 
mouth, or arms from as many portraits, three of the four. 
(29) Draws diamond shape from copy so that it can be recog- 
nised. (30) Names "red, green, blue, yellow" — matches colours. 

Mentality of 8 years. — (31) States difference between " paper and 
cloth, butterfly and fly, wood and glass " in two minutes, 
and two satisfactorily. (32) Counts from 20 to 100 in twenty 
seconds with not more than one error. (33) Names days of 
week in order in 10 seconds. (34) Counts value of six stamps, 
three ones and three twos, in less than 15 seconds. (35) 
Repeats five numerals in order when pronounced once. 

Mentality of 9 years. — (36) Gives correct change for 20 cents, 
(or 2 dimes); paid for an article costing 4 cents. (37) 

Defines in terms superior to statements of use, in No. 22. 
(38) Names day, month, day of month, year, allowing error 
of three days either way day of month. (39) Names the 
months in order, allowing one omission or inversion in 18 
seconds. (40) Arranges in order of weight boxes of same 
size and appearance, weighing 6, 9, 12, 15, and 18 grammes 
in 3 minutes; two out of three trials. 

Mentality of 10 years. — (41) Names a penny, nickel, dime, 
quarter, etc., in 40 seconds. (42) Copies design after 10 
seconds' exposure. (43) Repeats six numerals. (44) Tells 
what one should do in various emergencies, and answers 
questions difficult of comprehension. (45) Uses three given 
words in sentences. 

Mentality of 11 years. — (46) Detects nonsense in three out of 
five statements in about two minutes. (47) Uses three given 
words in one sentence. (48) Gives at least sixty words in 
three minutes. (49) Names three words that rhyme with 
" obey " in one minute. (50) Rearranges shuffled words of 
eight-word sentences, two out of three, with one minute for 
each. 



BINET-SIMON TESTS 255 

Mentality of 12 years. — (51) Repeats seven numerals in order 
when heard once. (52) Defines " charity, justice, goodness," 
two satisfactorily. (53) Repeats with no error sentence of 
23-26 syllables. (54) Resists suggestion as to length of lines. 
(55) Infers correctly the fact indicated by circumstances given 
in each of two trials. 
Mentality of 15 years. — (56) Interprets pictures shown in No. 10 
and 27. (57) Imagines clock-hands interchanged for hour 
6-20 and for hour 2-56, telling the time. (58) Writes "caught 
a spy " in symbols after leaving code, one error permitted. 
(59) Writes correctly the opposite of 17 out of 20 given words. 
Binet's articles were published in UAnnee Psychologique for 
1908, and in the Bulletin de la Societe hbre pour VEtude Psycho- 
logique de V Enfant for April, 1911. Dr. Goddard's article, " The 
Binet-Simon Measuring Scale for Intelligence," 1911, and the 
descriptive cases in his book, 1914, give good examples of the 
application of these tests, as does also Dr. Huey's book (1912), 
in which there is an excellent and full description of the tests 
and how to apply them. In School Hygiene for May, 1913, Dr. 
Kate Fraser gives a description of how to apply the tests. 



APPENDIX V 
CERTIFICATES AND FORMS 

(1) Schedule A for backward children — 

Elementary Education (Defective and Epileptic Children) 
Act, 1899. Mental Deficiency Act, 1913 



SCHEDULE A 

School (if any), 

Name of Child (in full), 

Date of Birth, 

I certify that this child is not incapable, by reason of mental 
defect, of receiving benefit from the instruction in an ordinary 
Public Elementary School. 



Signed 

Date Certifying Officer. 



256 APPENDIX V 

(2) Schedule B for special day or residential school cases — 
Elementary Education (Defective and Epileptic Children) 
Act, 1899. Mental Deficiency Act, 1913 



SCHEDULE B 

School (if any), 

Name of Child (in full), 

Date of Birth, 

I certify that this child, not being merely dull or backward, and 
not being an idiot, an imbecile, or a moral imbecile, is feeble- 
minded within the meaning of the Mental Deficiency Act, 1913, 
but is not incapable by reason of mental defect of receiving benefit 
from instruction in a special school or class under the Elementary 
Education (Defective and Epileptic Children) Act, 1899. 

Signed 

Date Certifying Officer. 

(3) Schedule C for cases needing custodial care — 

Elementary Education (Defective and Epileptic Children) 
Act, 1899. Mental Deficiency Act, 1913 



SCHEDULE C 

School (if any), 

Name of Child (in full), 

Date of Birth, 



I certify that this child is incapable, by reason of mental defect, 
of receiving benefit from instruction in a special school or class 
under the Elementary Education (Defective and Epileptic Chil- 
dren) Act, 1899. 

Note. — Under the Elementary Education (Defective and 
Epileptic Children) Act, 1899, idiots and imbeciles are excluded 
from special schools and classes certified under that Act. 



Signed 

Date Certifying Officer. 



ADMISSION FORMS 257 

(4) Schedule D for children who have been in a special day or 
residential school — 

Elementary Education (Defective and Epileptic Children) 
Act, 1899. Mental Deficiency Act, 1913 



SCHEDULE D 

School (if any), 

Name of Child (in full), 

Date of Birth, 



I certify that this child is incapable, by reason of mental defect, 
of receiving further benefit from instruction in a special school 
or class under the Elementary Education (Defective and Epilep- 
tic Children) Act, 1899. 



Signed 

Date Certifying Officer. 



(5) Schedule E for cases referred to the Board of Education under 
Section 81 (1) of Mental Deficiency Act — 

Elementary Education (Defective and Epileptic Children) 
Act, 1899. Mental Deficiency Act, 1913 



SCHEDULE E 

School (if any), 

Name of Child (in full), 

Date of Birth, 



I certify that this child cannot be instructed in a special school 
or class under the Elementary Education (Defective and Epileptic 
Children) Act, 1899, without detriment to the interests of the 
other children. 



Signed , 

Date Certifying Officer. 

R 



258 APPENDIX V 

The following forms are important, but, owing to consideration 
of space, they are not printed in full. The first can be obtained 
from the Government Stationery Offices : — 

(1) Schedule F of the Board of Education. This fills the four 
pages of a double sheet of foolscap, the first two and a half pages 
containing the points in relation to the medical examination 
divided under the following sub-headings : — 

(a) Particulars in relation to the child in school. 
(6) Home conditions. 

(c) Family history. 

(d) School history. 

(e) Personal Tiistory. 
(/) Physical condition. 
(g) Stigmata. 

(h) Mental condition, 
(t) Sensory mechanism. 
(j) Educational attainments. 
(k) Diagnosis. 

(1) Suggestions for treatment and training. 

and the remainder of the form being for (n) subsequent reports, 
(o) reports on leaving, and (p) reports after leaving. 

(2) Form used in accordance with 10 (a, 6) (11) of the Regula- 
tions for special schools issued by the Boaid of Education in 
1917, which reads as follows : — 

" The medical practitioner shall, if so directed by the Local 
Education Authority, or if so requested by the parent of 
the child, before giving a certificate consult the head 
teacher of the school, if any, which the child has been 
attending, or such other person as the Local Education 
Authority may appoint for the purpose, and a copy of any 
report made by the head teacher or such other person shall 
be forwarded to the Local Education Authority." 

This form is to be filled in by a teacher of an ordinary school 
sending a child to be examined with the view to admission to a 
special school or class for mentally defective children, and con- 
tains headings which, when filled in, give an idea of the attend- 
ance, behaviour, cleanliness, and general intelligence of the child. 

(3) Form F6, i.e., a form of application for admission of a 
Defective to Certified Institutions or Approved Homes issued by 
the Central Association for the care of the Mentally Defective. 



INSTITUTIONS 259 

This form is headed " Private and Confidential." It covers the 
four sheets of a double page of foolscap and asks for information — 

(a) With regard to the general behaviour and life history of the 
candidate. 

(6) Full information as filled in by a qualified medical practi- 
tioner. The medical information asked for is exhaustive, 
and covers the medical history of the present condition of 
the child, including all defects and abnormalities, the 
mental state, and the family history with regard to any 
hereditary taint. 



APPENDIX VI 

LIST OF INSTITUTIONS FOR MENTALLY DEFECTIVE CHILDREN IN 

ENGLAND AND WALES, SCOTLAND, IRELAND AND FOR THE 

FEEBLEMINDED AND EPILEPTIC IN AMERICA 

The following is a list of some of the larger of the Institutions 
in England and Wales dealing with children, compiled from a list 
kindly sent by the Board of Control, revised 17th September, 1919. 

A full list is given in the Annual Report of the Board of 
Control, Part II., published by His Majesty's Stationery Office, 
4/6 net. 

Certified Homes and Approved Homes are not included in the 
list for reasons of economy and space. Particulars of these can 
be obtained from the above report. 

In the following are given (1) county, (2) address, (3) names of 
managers or owners, (4) name of superintendent, and (5) numbers 
and classes of patients. 



STATE INSTITUTIONS 
(not for chdldren) 

1. Surrey. — Farmfield, Charlwood, Horley; the Board of Con- 

trol, 66 Victoria Street, London, S.WJ ; S.E. Gill, 

M.D. ; 95 female defectives of dangerous or violent 
propensities. 

2. Warwick. — Warwick State Institution, Warwick; the Board 

of Control, 66 Victoria Street, London, S.W.I; Miss 
M. I. Dick; female defectives of dangerous or violent 
propensities — number limited at present to 100. 



260 APPENDIX VI 

INSTITUTIONS CERTIFIED UNDER THE MENTAL 
DEFICIENCY ACT, 1913 

1. Cheshire. — Sandlebridge, Alderley Edge; Lanes, and Cheshire 

Society for Permanent Care; Miss Grace Wyatt; 295 
higher-grade defectives of either sex. Certified by Board 
of Education for 115 boys and 85 girls. 

2. Derby. — (a) The Hopewell Hall Colony, near Derby; Notts 

Association for Permanent Care; Mrs Harriet M. Swin- 
burne; 16 male feebleminded cases over the age of 
seven years. Certified by Board of Education for 88 
cases. 

(b) Whittington Hall (Midland Counties Institution), 
Chesterfield; The Incorporation of National Institutions 
for Persons requiring Care and Control; Warden — Rev. 
H. N. Burden, 14 Howick Place, Victoria Street, London, 
S.W.I; Miss Ellen Smith; 400 female patients— all 
grades of mental defect, majority over school age. See 
also Stoke Park, Bristol. 

3. Devon. — Western Counties Institution, Starcross, near Exeter; 

Committee of Management; E. W. Locke; 230 males 
and 106 females. Certified by Board of Education for 83 
boys or girls. 

4. Essex. — (a) Bigods Hall, near Dunmow; Committee of 

Management; Sister Mary A. Ryan; 6 male patients; 
imbeciles and feebleminded up to the age of sixteen 
years. 

(6) Royal Eastern Counties Institution, Colchester; 
Board of Directors; F. D. Turner, M.B. ; 512 male and 
female patients; certified by Board of Education for 82 
boys or girls ; 60 female patients, of whom not more than 
10 shall be high-grade cases over 16 and not exceeding 
24 years of age, the remainder to be educable and of 
school age. 

5. Gloucester. — Stoke Park and other premises, Bristol; The 

Incorporation of National Institutions for Persons re- 
quiring Care and Control; Miss Gladys Williams; 1,578 
defectives of all classes within the meaning of the Act, 
including young children. 

6. Herts. — (a) Hillside, Buntingford, Hertford : Westminster 

Diocesan Education Fund; Sister Catherine O'Toole; 40 
male patients, being cases of an age and of a degree of 
mental defect such as would permit of their being housed 
and instructed with children for whom the school is 
primarily intended. 



fa 



INSTITUTIONS— ENGLAND 261 

(o) St. Elizabeth's Home for Epileptics, Much Hadham; 
Committee; Sister Mary Edmund; school, 3 males and 
3 females; certified by Board of Education for 14. boys 
and h% girls; colony, 80 adult females; idiots, imbeciles, 
and feebleminded cases of the Roman Catholic religion. 

7. Kent. — Princess Christian's Farm Colony, Hildenboro', Kent. 

National Association for the Feebleminded; Miss Pit- 
man; 60 males, 68 females. 

8. Lancashire. — (a) Allerton Priory R.C. Special (M.D.) School, 

Woolton, Liverpool; Board of Management; Sister 
Catherine Flannery; 5 males and 10 females; feeble- 
minded cases under the age of 16 years and such as can 
be conveniently and properly trained with the other chil- 
dren in the Institution. Certified by Board of Education 
for 21{. boys and 82 girls. 

(6) Brockhall, Langho, near Blackburn; Lancashire 
Asylums Board; Sir Harcourt E. Clare (Clerk); F. A. 
Gill, M.D. ; 258 female imbeciles, feebleminded, and 
moral imbeciles; only Lancashire cases are received, and 
idiots and epileptics are not received. 

(c) Dovecot (Horticultural School), Knotty Ash, Liver- 
pool; The Liverpool Ladies' Association for the Care and 
Training of Girls; Miss Florence Eyre; 15 high-grade 
feebleminded girls; age on admission from 10 to 12 
years; Roman Catholics not received. Certified by Board 
of Education for 36 girls. 

(d) Pontville R.C. Special School, Aughton, Ormskirk; 
Committee; Sister C. Cullinan; 10 male patients; 
Roman Catholic feebleminded children between the ages 
of 5 and 16 years. Certified by the Board of Education 
for 98 boys and 15 girls. 

(e) Royal Albert Institution, Lancaster; Central Com- 
mittee of Management; W. H. Coupland, L.R.C.P., 
L.R.C.S.Ed.; 461 males and 289 females. 

9. London. — (a) 39 Downs Road, Clapton, E.5, with ancillary 

premises; The Committee of the Girls' Training Homes, 
Clapton ; Miss Emma Aubery ; 25 feebleminded cases of 
the female sex aged 8 years and upwards, all of childish 
attainments and habits; must be Protestants; not more 
than two to be private patients. 

(b) South Side Home, Streatham Common, S.W.16; 
The London Asylums and M.D. Committee; Miss Eliza- 
beth J. Price; 80 females; imbeciles, feebleminded, and 
moral imbeciles; higher-grade cases, chiefly above 16 
years of age, but including some younger children and 



262 APPENDIX VI 

physically defective cases, to be accommodated on the 
ground floor; reserved for London cases only. 

10. Middlesex. — (a) Crathorne, Oak Lane, East Finchley, N.2; 

The Committee of the Finchley Home for Feebleminded 
Mothers and their Children; Hon. Secy., Mrs Moss- 
Blundell, 7 North Grove, Highgate, London, N. ; Miss 
Emma D. Saltwell; 32 mothers and their children who 
are feebleminded or moral imbeciles; the number of 
mothers never to exceed 20, and no child to be retained 
beyond the age of 7 years; Poor Law cases received. 

(b) Pield Heath House School, Hillingdon, Uxbridge; 
Committee; Sister Winefride Tyrrell; 10 females; 
feebleminded and moral imbeciles of the Roman Catholic 
religion. Certified by Board of Education for 62 girls. 

11. Somerset. — (a) Rock Hall House (Magdalen Hospital School), 

Combe Down, Bath; Municipal Charity Trustees of the 
City of Bath; Miss Jane Quinton; 38 children of both 



(6) Stoke Park, Bristol, with ancillary premises. (See 
under County of Gloucester.) 

12. Surrey. — The Royal Earlswood Institution for Mental Defec- 

tives, Redhill; Board of Management; C. Caldecott, 
M.B. ; about 600 patients of both sexes. 

13. Warwick. — Midland Counties Institution, Knowle, near Bir- 

mingham; General and Managing Committee; A. H. 
Williams; 150 patients of both sexes. 

14. Worcester. — Besford Court Home, near Defford; Committee 

of Management; Rev. T. A. Newsome; 7 male and 5 
female defectives; cases of an age and of a degree of 
mental defect such as would permit of their being housed 
and instructed with the children for which the school is 
primarily intended; and 25 additional defectives over 16 
years and under 21 years of age, of whom not more than 
19 are to be females. Certified by Board of Education 
for 73 boys and J+6 girls. 

15. Yorkshire.— (a) Bradford County; Ashfield, 269 Thornton 

Road, Thornton, near Bradford; County Borough Council 
of Bradford ; F. H. Macdonald ; 36 male patients, able 
bodied, over the age of 7 years. 

(b) West Riding, Leeds County; Meanwood Park 
Colony, Meanwood, Leeds; County Borough of Leeds; 
Miss Frances Cooke; 35 males and 52 females; idiots, 
imbeciles, and feebleminded — male cases to be not more 
than 14 years of age. 



APPROVED PREMISES— ENGLAND 263 

PREMISES APPROVED UNDER SECTION 37, 
MENTAL DEFICIENCY ACT, 1913 

17. Essex. — The Forest Gate Sick Home, Forest Lane, West 

Ham; The Guardians of the West Ham Union; J. S. 
Greig; 10 male and 30 female adult defectives, and 10 
male and 15 female defectives under the age of 16 years; 
all classes within the meaning of the Act. Certified by 
Board of Education for 15 cases. 

18. Kent. — The Poor Law Institution, Tenterden; The Guardians 

of the Tenterden Union; Master of the Institution; 55 
female defectives; all classes within the meaning of the 
Act; 35 girls 5-21 years of age. no low-grade cases. 

19. Lancashire. — Seafield House, Seaforth, near Liverpool; The 

Guardians of the West Derby Union; S. J. Towill; 80 
males and 189 females of all classes under the Act. 

20. London. — The Metropolitan Asylums Board Certified Institu- 

tion; The Metropolitan Asylums Board, Embankment, 
London, E.C.4; Darenth Industrial Colony and Bridge 
Industrial Home, Witham; E. B. Sherlock, M.D.; 
Juvenile trainable cases; Leavesden Asylum, F. A. 
Elkins, M.D., unimprovable children and adults; Caterham 
Asylum, P. E. Campbell, M.B., unimprovable children 
and adults; Fountain Temporary Asylum, J. L. Gordon, 
M.D., idiot children. 

21. Middlesex. — (a) Fortescue Villas, Gentleman's Row, Enfield; 

The Guardians of the Edmonton Union; E. B. Willett, 
M.D. ; 32 female defectives under the age of 16 years — 
idiots, imbeciles, and a limited number of feebleminded 



(b) Warkworth House, Isleworth; The Guardians of 
the Brentford Union; A. Milsom; 38 males; idiots 
and imbeciles (children). 

22. Northumberland. — Prudhoe Hall Colony and Burn House, 

Pruclhoe-on-Tyne ; The Northern Counties Joint Poor 
Law Committee, South Shields; Miss Nesta M. Hawkes; 
185 defectives, of whom not more than 80 shall be males 
and not more than 105 shall be females; 89 females at 
Prudhoe Hall Buildings, 16 females at Burn House, and 
80 males at New Blocks; children of all grades of mental 
defect received but chiefly the higher grades. 

23. Stafford. — Great Barr Park, Great Barr, near Birmingham; 

The Walsall and West Bromwich Unions Joint Com- 



264 APPENDIX VI 

mittee ; W. Maule Smith, M.D. ; 40 male adult defectives 
and 40 boys under the age of 16 years ; all classes within 
the meaning of the Act. 

24. /Westmorland. — The Poor Law Institution, Milnthorpe; The 
Guardians of the Kendal Union ; C. Matthews ; 72 defec- 
tives, consisting of 23 adult males, 21 adult females, and 
28 children; all classes within the meaning of the Act. 

25. Birmingham. — Monyhull Colony, King's Heath; The Guar- 
dians of the Birmingham Union; Miss Mary J. Carse; 
80 male and 80 female defectives; those under 5 and 
over 40 years of age, as well as those incapable of being 
trained, excluded. 



LIST OF INSTITUTIONS IN SCOTLAND 
Kindly supplied by the General Board of Control, Scotland. 

1. Dundee. — Baldovan, near Dundee; Dr. Drummond; 260 

beds; all classes of children under the Mental Deficiency 
Act. 

2. Bridge-of-Weir.— Bridge-of-Weir; Dr. Crocket; 112 beds; 

licensed to receive educable children of Protestant religion 
and of school age; also receives epileptics. 

3. Larbert. — Larbert; Dr. Clarkson; 500 beds; all classes of 

children under the Mental Deficiency Act. 

4. Glasgow. — St. Charles, Whiteinch, Glasgow; Sister McDon- 

nell ; 70 beds ; educable defectives of the Roman Catholic 
religion between 5 and 16 years of age. 

5. Kirkintilloch. — Waverley Park, Kirkintilloch; Mr A. H. 

Charteris; 90 beds; educable defective girls between 
5 and 16 years of age. 



LIST OF INSTITUTIONS IN IRELAND 

1. Co. Dublin. — Stewart Institution, Palmerston, Co. Dublin; 
F. E. Rainsford, M.D. ; for idiotic and imbecile children 
and hospital for mental diseases; for Protestant children 
only. Certified inmates, 113, i.e., 78 boys and 35 girls. 



INSTITUTIONS IN AMERICA 265 

LIST OF PUBLIC INSTITUTIONS FOR THE FEEBLE- 
MINDED AND THE EPILEPTIC IN THE 
UNITED STATES 

From a list kindly supplied by Dr. Walter E. Fernald, M.D., 
and given in his publication, " The Growth of Provision for the 
Feebleminded in the United States." The National Committee for 
Mental Hygiene, Inc., 50 Union Square, New York City. Second 
Printing, 1919. 

1. Arkansas. — Institution authorised. For feebleminded. 

2. California.— Sonoma State Home, Eldridge. F. O. Butler, 

M.D. For feebleminded and epileptics. Capacity, 1,345. 

3. Colorado. — State Home and Training School for Mental Defec- 

tives, Arvada (P.O., Ridge). A. P. Busey, M.D. For 
feebleminded and epileptics. Capacity, 81. 

4. Connecticut. — Mansfield State Training School and Hospital : 

(a) Colony for Epileptics, Mansfield Depot. (6) Training 
School for Feebleminded, Lakeville. Charles T. La 
Moure, M.D. Capacity, 550. 

5. Delaware. — Institution authorised. For feebleminded. The 

State supports 13 feebleminded at the Training School for 
Feebleminded Children, Elwyn, Pennsylvania. 

6. District of Columbia. — The District supports 45 feebleminded 

at the Training School for Feebleminded Children ; Elwyn, 
Pennsylvania, and maintains others in private institutions 
in Virginia and New Jersey. 

7. Idaho. — State Sanitarium, Nampa. For both feebleminded 

and epileptics. Building partially erected. 

8. Illinois. — (a) Industrial Colony for Improvable Epileptics, 

Dixon, (b) Lincoln State School and Colony, Lincoln. 
T. H. Leonard, M.D. For feebleminded. Capacity, 2,000. 

9. Indiana. — (a) School for Feebleminded Youth, Fort Wayne, 

George S. Bliss, M.D. For feebleminded girls and boys 
6 to 16 years old, and feebleminded women 16 to 45. 
Capacity, 1,391. (b) Village for Epileptics, New Castle. 

10. Iowa. — (a) Institution for Feebleminded Children, Glenwood. 

George Mogridge, M.D. Established and opened 1876. 
For feebleminded. Capacity, 1,500. (b) State Hospital 
and Colony for Epileptics, Woodward. 

11. Kansas. — (a) State Home for Feebleminded, Winfield. F. C. 

Cave, M.D. For Feebleminded. Capacity, 700. (b) 
State Hospital for Epileptics, Parsons. 

12. Kentucky. — State Institution for the Feebleminded : — (a) 



266 APPENDIX VI 

Training School for the Feebleminded, Frankfort. S. L. 
Helm, M.D. Established 1860, opened 1861. Admits 
feebleminded children 6 to 18 years old, who can be 
educated or trained. Capacity, 400. (b) Farm Colony for 
the Feebleminded. 

13. Maine. — School for Feebleminded, West Pownal. Carl J. 

Hedin, M.D. Admits feebleminded males between 6 and 
40 years, females between 6 and 45 years. Capacity, 283. 

14. Maryland. — Rosewood State Training School, Owings Mills. 

Frank W. Keating, M.D. For feebleminded. Capacity, 
700. 

15. Massachusetts. — (a) School for Feebleminded, Waltham 

(Waverley P.O.). Walter E. Fernald, M.D. Established 
and opened 1848. For feebleminded children. Capacity, 
1,625 (including about 300 in Colony at Templeton). (b) 
Monson State Hospital, Palmer, (c) School for Feeble- 
minded, Belchertown. Authorised but not yet built, (d) 
Wrentham State School, Wrentham. George L. Wallace, 
M.D. For feebleminded. Capacity, 1,200. 

16. Michigan. — (a) Farm Colony for Epileptics, Wahjamega 

(Caro P.O.). (6) Home and Training School, Lapeer. 
H. A. Haynes, M.D. For feebleminded over 6 years. 
Capacity, 1,481. 

17. Minnesota. — School for Feebleminded and Colony for Epilep- 

tics, Faribult. For feebleminded and epileptics. 
Capacity, 1,600. 

18. Missouri. — Colony for Feebleminded and Epileptics, Marshall. 

R. P. C. Wilson, M.D. Capacity, 1,000. 

19. Montana. — Training School for Backward Children, Boulder. 

Herbert J. Menzemer. For feebleminded children. 
Capacity, 94. 

20. Nebraska. — Institution for the Feebleminded, Beatrice. D. 

G. Griffiths, M.D. For feebleminded. Capacity, 600. 

21. New Hampshire. — School for Feebleminded, Laconia. B. W. 

Baker, M.D. For feebleminded children. Capacity, 280. 

22. New Jersey. — (a) State Institution for Feebleminded, Vine- 

land. Madeleine A. Hallowell, M.D. For feebleminded. 
Capacity, 7S5. (b) State Village for Epileptics, Skillman. 
(c) The State maintains 380 feebleminded children, some 
entirely, some partially, in the Training School at Vine- 
land — a private institution. An appropriation of $15,000 
was made by the Legislature of 1916 for the establish- 
ment of colonies for the feebleminded on forest reserves 
or other State lands. 

23. New York.— (a) Craig Colony for Epileptics, Sonyea. (b) 



INSTITUTIONS IN AMERICA 267 

Letchworth Village, Thiells. F. J. Russell, M.D. For 
feebleminded and epileptics of unsound mind, not insane. 
Capacity, 330. (c) New York City Children's Hospital 
and Schools, Randall's Island. J. F. Vavasour, M.D. 
For feebleminded and epileptic children of New York 
City. Capacity, 1,940. (d) Rome State Custodial Asylum, 
Rome. Charles Bernstein, M.D. For feebleminded. 
Capacity, 1,580. (e) State Custodial Asylum, Newark. 
Ethan A. Nevin, M.D. For feebleminded women of child- 
bearing age. Capacity, 1,050. (/) Syracuse State Institu- 
tion for Feebleminded Children, Syracuse. O. Howard 
Cobb, M.D. Established and opened 1851. For feeble- 
minded children under 16 years old capable of improve- 
ment. Capacity, 607. 

24. North Carolina. — (a) Caswell Training School, Hines (Kinston 

P.O.). C. B. M'Nairy, M.D. For feebleminded over 6 
years old. Capacity, 200. (6) State Colony for Epilep- 
tics, Raleigh. 

25. North Dakota. — Institution for Feebleminded, Grafton. A. 

R. T. Wylie, M.D. For feebleminded and epileptics. 
Capacity, 263. 

26. Ohio. — (a) Institution for Feebleminded, Columbus. E. J. 

Emerick, M.D. Established and opened 1857. For 
feebleminded. Capacity, 2,200. (b) Hospital for Epilep- 
tics, Gallipolis. 

27. Oklahoma. — Institution for Feebleminded, Enid. W. L. 

Kendall, M.D. For feebleminded 5 to 16 years old; if 
over 16 maintenance must be paid. Capacity, 400. 

28. Oregon. — State Institution for Feebleminded, Salem. For 

feebleminded and epileptics. Capacity, 310. 

29. Pennsylvania. — (a) Eastern Pennsylvania State Institution for 

the Feebleminded and Epileptic, Spring City. William 
J. Steward, M.D. For feebleminded and epileptics. 
Capacity, 1,159. (6) State Institution for Feebleminded 
of Western Pennsylvania, Polk. J. M. Murdoch, M.D. 
For feebleminded. Capacity, 1,773. (c) Village for 
Feebleminded Women, Laurelton. Mary M. Wolfe, 
M.D. To be opened September, 1919. For feebleminded 
women of child-bearing age. (d) The State maintains 700 
feebleminded children at the Training School for Feeble- 
minded Children, Elwyn, and 30 children in the Pennsyl- 
vania Epileptic Hospital and Colony Farm at Oakbourne 
— both private institutions, (e) The City of Philadelphia 
is now erecting a large institution for its feebleminded 
at Byberry, a suburb. 



268 APPENDIX VI 

30. Rhode Island. — Exeter School, Exeter (Slocum P.O.). Joseph 

H. Ladd, M.D. For feebleminded. Capacity, 330. 

31. South Carolina. — Institution authorised. 

32. South Dakota. — State School and Home for the Feebleminded, 

Redfield. J. K. Kutnewsky, M.D. For feebleminded 
and epileptics. Capacity, 303. 

33. Texas. — (a) State Colony for the Training of the Feeble- 

minded, Austin. J. W. Bradfield, M.D. (b) State 
Epileptic Colony, Abilene. 

34. Vermont. — State School for the Feebleminded, Brandon. 

T. J. Allen, M.D. For feebleminded children 5 to 21 
years old. Capacity, 171. 

35. Virginia. — (a) Colony for Feebleminded. A department of the 

State Epileptic Colony for white women of child-bearing 
age. Capacity, 112. A colony for negro feebleminded 
was established in 1914 (not yet opened) as a department 
of the Central State Hospital for the Insane at Peters- 
burg, (b) State Epileptic Colony, Madison Heights (near 
Lynchburg). 

36. Washington. — State Institution for Feebleminded, Medical 

Lake. S. C. Woodruff. For feebleminded and epileptic 
children under 21 years and feebleminded adults under 
50 years. Capacity, 600. 

37. Wisconsin. — (a) Southern Wisconsin Home for the Feeble- 

minded and the Epileptic, Union Grove. H. C. Werner, 
M.D. Capacity, 300 at opening; when completed capa- 
city will be 1,476. (b) Home for Feebleminded, Chippewa 
Falls. Alfred W. Wilmarth, M.D. For feebleminded. 
Capacity, 1,160. 

38. Wyoming. — State School for Defectives, Lander. J. H. 

Hutchins, M.D. For feebleminded and epileptics. 
Capacity, 100. 



Further particulars regarding Institutions and Homes can be 
found in : — 

The Reports of the Central Association for the Care of the Ment- 
ally Defective. Hon. Secy., Miss Evelyn Fox, Queen Anne's 
Chambers, Tothill Street, Westminster, London, S.W.I. 

The Annual Charities Register and Digest. Longmans & Co. 

Burdett's Hospitals and Charities. London : The Scientific 
Press, Ltd. 

The Medical Directory. London : Churchill. 

The List of Certified Schools for Blind, Deaf, Defective, and 



SOCIETIES 269 

Epileptic Children in England and Wales, issued by the 
Board of Education. Wyman & Sons. 
Classified List of Institutions, published by the Reformatory and 

Refuge Union, 117 Victoria Street, London, S.W.I. 
List of Institutions, Certified Houses, and Approved Homes, 
issued by the Board of Control, 66 Victoria Street, London, 
S.W.I. 
Reports and Publications, issued by Societies dealing with the 
Feebleminded, set forth on page 281. 
The following are the addresses of Societies dealing with the 
mentally defective : — 

The Central Association for the Care of the Mentally Defective. 
Hon. Secy., Miss Evelyn Fox, Queen Anne's Chambers, Tot- 
hill Street, Westminster, London, S.W.I. 
The National Association for the Feebleminded, Denison House, 

296 Vauxhall Bridge Road, S.W. 
Glasgow Association for the Care of the Feebleminded. Hon. 

Secy., A. H. Charteris, 19 St. Vincent Place, Glasgow. 
Lancashire and Cheshire Society for the Permanent Care of the 
Feebleminded. Hon. Secy., Mr J. S. Walker, 1 Brazennose 
Street, Manchester. 
The Charity Organisation Society, Denison House, Vauxhall 

Bridge Road, S.W.I. 
The Metropolitan Asylums Board, Victoria Embankment, E.C.4. 
The Incorporation of National Institutions for Persons requiring 
Care and Control. Warden, Rev. H. N. Burden, 14 Howick 
Place, Victoria Street, S.W.I. 
Association for the Employment of the Physically and Mentally 
Defective. Hon. Secy., Miss Arnould, 39 Lillie Road, 
London, S.W. 
Brighton Guardianship Society. Secy., Miss Woodhead, 82 

Grand Parade, Brighton. (For boarding out defectives.) 
Westminster Diocesan Education Fund. Secy., Mr T. W. Hunter, 
Archbishop's House, Westminster, S.W.I. (Roman Catholic 
Schools and Homes.) 
Homes for Catholic Defective Children. Administrator, Rev. 

T. A. Newsome, Besford Court, Worcestershire. 
Society of the Crown of Our Lord. Secy., Miss B. James, 10 
Burton Court, Sloane Street, London, S.W.I. (Home for 
Feebleminded Girls.) 
Committee of the Association for Helping Deficient Children, 

20 Gower Street, London, W.C.l. 
Local Associations for the Care of the Mentally Defective. These 
number about 40, and they work in conjunction with the Local 
Statutory Authorities. A list of the Local Associations with 



270 APPENDIX VII 

extracts of their Annual Reports will be found in the Annual 
Reports of the Central Association for the Care of the 
Mentally Defective. 



APPENDIX VII 

PLANS AND DESCRIPTION OF THE " WYATT " HOUSE AT SANDLEBRIDGE, 
A BUILDING SUITABLE FOR A RESIDENTIAL SCHOOL 

Published by the kind permission of the Board of Governors of 
the Sandlebridge Colony. 

The building is divided into two parts by rooms for administra- 
tion occupied by the Matron and Staff. A service staircase is 
provided in the centre of the building, by which the Matron and 
Staff have access to all the rooms, but each wing is strictly reserved 
for the children for whom it is provided. 

The girls' side consists of dining-room, play-room, cloak-rooms, 
etc., on the ground floor, and above on the first floor are two 
dormitories, each supervised from an adjacent room (which is occu- 
pied by a member of the staff), bathrooms and lavatories with hot 
and cold water. 

The boys' part is on the other side of the building, and consists 
of similar accommodation. Each wing is provided with a well- 
constructed staircase for the use of the children. 

There are no internal latrines in the building — these are pro- 
vided in the yard. In case of sickness a room for an earth closet 
is provided in each wing. 

The building is of plastic (Accrington) brick, with terra cotta 
facings throughout. All the rooms have tiled dadoes, the walls 
above dado height being finished in plaster. 

The heating throughout is by open fireplaces, all provided with 
fireguards. There is an ample supply of town's water from the 
public mains. 

The scheme has been to provide a building of first-class charac- 
ter without any extravagance. Internal passages have, as far as 
possible, been dispensed with. All windows are made to open top 
and bottom. A distinct feature of the building is that there is 
not a dark corner in any of the rooms. There are wash bowls 
at the entrance of each wing. The floors are of wood throughout 
with the exception of kitchen, bathroom, and lavatories; these 
are of lignite, an impervious flooring material, which has the 
advantage of being warmer than concrete. 

The cost for 65 children worked out at £74 a head in 1905. 




-Attic Plan- 




First Floor Plan — 




Seals of Feet. 

05 lp ._ 2.0 3P 



^ Ground Floor m Plan . 



272 



APPENDIX VII 



SANDLEBRIDGE COLONY— WYATT HOUSE 

Time Table 



6.30 


a.m. 


6.45 


a.m. 


7.0 a.m. 


8.0 a.m. 


8.30 


a.m. 


8.40 


a.m. 


9.30-12.0 noon, 



12.0 noon. 
1.0 p.m. 



2.0-3.30 p.m. 



3.30-4.15 p.m. 
4.15 p.m. 
4.30 p.m. 

5.30 p.m. 
6.15 p.m. 
7.0-7.30 p.m. 

Bathing- 



Monday to Friday inclusive. 

Staff arise. 

Children arise and dress. 

Bedmaking, dormitory cleaning, by older boys 
with attendant. Younger boys taken down 
by the attendant; boots cleaned; washed for 
breakfast. 

Breakfast for children and Staff, prepared and 
served by the cook; older boys assist. 

Prayers. 

Older boys with attendants wash up, tidy 
dining-rooms, and get ready for school. 
Younger boys got ready for school by 
attendant. 

School.* The house boys finish dining-rooms, 
offices, yard, tidy up the paths and sweep up 
the shed. Two house boys help housemaid 
with Staff rooms. Cook prepares dinner for 
children and Staff. Attendants do the mend- 
ing and making of clothes during school 
hours. 

Dinner for children and Staff. 

Younger boys play until school time. Older 
boys with attendants wash up, clean up in 
kitchen, tidy up dining-rooms, and prepare 
for school. 

School.* House boys tidy up generally. Some- 
times go for a walk, sometimes employed in 
repairing stockings and knitting, and sundry 
other occupations. 

Games for all, with attendant. 

Older boys clean their own boots. 

Strip wash for all, followed by tooth-brush 
drill, with attendant. 

Tea for children. 

Prayers and preparation for bed. 

Bed-time. 
-Tuesday, Thursday, and Friday nights. 



* In the Thomasson and Sam Gamble day school adjoining. 



6.30-8.40 a.m. 
8.40 a.m. 



12.0-2.0 p.m. 

2.0 p.m. 

From 4.15 p.m. 



DAILY ROUTINE 

Saturday. 



273 



Usual routine. 

All buttons, boots, clothing overlooked and re- 
placed, which usually takes up all the morn- 
ing. 

Usual routine. 

Games or walks according to weather. 

Usual routine. All boots cleaned. 



Sunday. 

Rise half an hour later. Usual routine 
done, except that there are no boots 
until dinner time. 

12.0-2.0 p.m. Usual routine. 

2.0-3.0 p.m. Sunday School. 

3.0-4.30 p.m. Quiet time with books. 

From 4.30 p.m. Usual routine. 



till the tidying up is 
to clean ; then a walk 



BIBLIOGRAPHY 



A. Idiocy, Imbecility, and Feeblemindedness 
Books 

Ashby and Wright. " Diseases of Children." 5th Edition, 

1905. Longmans, Green & Co., London. 
Barr, M. W. " Mental Defectives, their History, Treatment, 

and Training." Rebman Ltd. London, 1904. 
Beach, F., and Shuttleworth, G. E. " Idiocy and Imbecility," 

in Sir Clifford Allbutt's "System of Medicine," vol. viii. 

London : Macmillan, 1899 ; and in Hack Tuke's " Dictionary 

of Psychological Medicine." London, 1892. 
Crowley, R. H. " The Hygiene of School Life." London : 

Methuen & Co., 1909. 
Goddard, H. H. " Feeblemindedness, its Causes and Conse- 
quences." Macmillan Publishing Co., New York, 1914. 
Huey, E. B. A. M., Ph.D. "Backward and Feebleminded 

Children." Educational Psychology Monographs. Baltimore : 

Warwick & York, 1912. 
Ireland, W. W. " The Mental Affections of Children." Second 

Edition, 1900. London : J. and A. Churchill. 
Mackenzie, L. " The Medical Inspection of School Children." 

Edinburgh, 1904 and 1909. 
Norsworthy, N. " The Psychology of Mentally Deficient 

Children." New York, November, 1906. 
Petersen and Church. " Text Book of Nervous and Mental 

Disease." Fourth Edition, 1904. 
Preyer. " The Mind of the Child." 1894. 
Savage, G. H. " Insanity and Allied Neuroses." London : 

Cassel & Co. 
Sherlock, E. B. 

London, 1911. 
Shuttleworth, G. E., and Potts 

Children 

London : 



The Feebleminded.' 



Macmillan & Co., 



W. A. " Mentally Defective 
their Treatment and Training." Third Edition. 
H. K. Lewis, 1910. 



275 



276 BIBLIOGRAPHY 

Starr, Louis. " Text Book of Diseases of Children." Lon- 
don, 1900. 
Still, G. F. " Common Disorders and Diseases of Childhood." 

London : Frowde, Hodder & Stoughton, 1909. 
Thomson, John. " Guide to the Clinical Examination of Sick 

Children." Second Edition. Edinburgh, 1908. 
Tredgold, A. F. " Mental Deficiency." 1914. Second Edition. 

London : Balliere, Tindall & Cox. 
Warner, F. " Dull, Delicate, and Nervous Children," in Sir 

Clifford Allbutt's " System of Medicine." Vol. viii., p. 198. 
Whipple, G. M. " Manual of Mental and Physical Tests." 

Part 1, Simpler Processes; Part 2, Complex Processes. 

Baltimore : Warwick & York, 1914. 
Wyllie, John. " Disorders of Speech." Edinburgh, 1894. 
Young, Meredith. "The Mentally Defective Child." H. K. 

Lewis & Co. Ltd., May, 1916. 



Articles. 

Andriezen, W. L. " Pathogenesis of Epileptic Idiocy and Epi- 
leptic Imbecility." British Medical Journal, May 1st, 1897. 

Asexualization. " Articles and Discussion on." Journal of 
Psycho-Asthenics, June, 1905. 

Ashby, H. " Speech Defects in Relation to Mentally Deficient 
Children." Medical Chronicle, 1903-04, p. 4. 

Berry, R. J. A., and Porteus, S. D. " A Practical Method for 
the Early Recognition of Feeblemindedness and other Forms 
of Social Inefficiency." The Medical Journal of Australia., 
vol. II., 5th year, No. 5. August 3rd, 1918. 

Binet, A., and Simon, T. " Sur la necessity d'etablir un diagnos- 
tic scientifique des 6tats inferieurs de l'intelligence." Archiv 
Psychologie, 11, 1905, pp. 163-190. 

Binet, A., and Simon, T. " Methodes nouvelles pour le diagnos- 
tic du niveau intellectuel des anormeaux." Ibid. 194-244. 

Binet, A., and Simon, T. " Application des methodes nouvelles 
au diagnostic du niveau intellectuel chez des en f ants normaux 
et anormaux d'hospice et d'6cole primaire." Ibid. 245-336. 

Binet, A., and Simon, T. " Le deVeloppement de l'intelligence 
chez les enfants." Archives de Psychologie, Geneva, Switzer- 
land. 14, 1908, pp. 1-94. 

Binet, A., and Simon, T. " L'intelligence des Inibeciles." 
Archives de Psychologie. Quarterly, 1919, pp. 1-147. 



ARTICLES 27? 

Bolton, J. " The Functions of the Frontal Lobes." Brain, 
vol.. 26, 1903. 

" Amentia and Dementia." Journal of Mental Science, 

April, 1905, et seq. 

Bournville. " L'Epilepsie, L'Hysterie et L'Idiotie." Paris, 
1903-1907. 

Burr, C. W. " Care of Feebleminded." Archives of Pediatrics. 
February, 1918. 

Bury, J. S. " The Influence of Hereditary Syphilis on the Pro- 
duction of Idiocy and Imbecility." Brain, Part xxi, vol. vi, 
p. 44. 

Clark, L. Pierce, and Stowell, Wm. L. " A Study of Mentality 
in 4,000 Feebleminded and Idiots." New York Medical 
Journal, February 22nd, 1913, p. 376. 

Clarkson, R. D. "Children who never grow up." Falkirk: 
John Callender, 1909. 

Dean, H. R. " An Examination of the Blood Serum of Idiots 
by the Wasserman Reaction." Proceedings of the Royal 
Society of Medicine; Neurolog. Sect., vol. iii, No. 9, 
July, 1910. 

Decroly, O., and Degand, Mdlle. " Les Tests de Binet et 
Simon pour la mesure de l'intelligence. Contribution 
critique." Archiv Psychologie, 6, 1906, pp. 27-130; and 
Archiv Psychologie, 9, 1910, pp. 81-108. 

" The Defective Delinquent." Papers read at the Annual Con- 
ference of the Massachusetts Society for Mental Hygiene. 
January, 1918. Boston. 

Dendy, Mary. " The Feebleminded." The Economic Review, 
July, 1903. 

" Workers or Wastrels." Charity Organisation Review, 

November, 1909. 

" The Problem of the Feebleminded." The Manchester 



Statistical Society, March, 1908. 

Dundas, J. " Mental Deficiency in Children." Practitioner, 
September, 1909. 

Fernald, W. E. " The History of the Treatment of the Feeble- 
minded." Boston, 1893. 

" Standardized Fields of Inquiry for Clinical Studies of 

Borderline Defectives." Mental Hygiene, vol. L, No. 2, 
pp. 211-234. April, 1917. 

" Diagnosis of the Higher Grades of Mental Defect. 

American Journal of Insanity, vol. 70, No. 3. January, 1914. 

" The Diagnosis of the Higher Grades of Mental 

Deficiency." American Journal of Insanity, vol. 70, No. 3. 
January, 1914. 



278 BIBLIOGRAPHY 

Forbes, D. " An Experiment in the Treatment of Backward 
Children." London County Council Conference of Teachers. 
January 5th, 1912. 

Fraser, Kate. *' Use of Binet-Simon Tests with regard to Admis- 
sion to a Special School." School Hygiene. May, 1913. 

Goddard, H. H. " The Binet and Simon Tests of Intellectual 
Capacity." Training School. December 5th, 1908, 3-9. Re- 
printed as " The Grading of Backward Children." New 
Jersey Training School Dept. of Psychological Research. 
Vineland. August, 1919. 

" The Binet-Simon Measuring Scale for Intelligence." 

Ibid., 1911. 

Two Thousand Normal Children Measured by the Binet 



Measuring Scale of Intelligence." Pedagog. June, 1911. 
" Four Hundred Feebleminded Children." September, 1910, 
vol. XVIII., pp. 232-239. 

Gordon, R. L. " The Influence of Inherited Syphilis in Mental 
Deficiency." Lancet, September 20th, 1913. 

Hinshelwood, J. " Congenital Word Blindness." Lancet, May 
26th, 1900, p. 1506; also London, 1900, H. K. Lewis. 

Lapage, C. P. " Feeblemindedness in Children." Medical 
Chronicle, 1905, Nos. 251-253, vol. xlii and xliii. Manchester: 
Sherratt and Hughes. 

" The Diagnosis of Permanent Mental Deficiency in 

Infancy and Childhood." Practitioner, August, 1909. 

MoIlraith, J. " The Aetiology of Convulsions in Infancy and 
Childhood." Medical Chronicle, December, 1906, and Janu- 
ary, 1907. 

Makuen. " Two Hundred Cases of Speech Defects." The 
Therapeutic Gazette, September 17th, 1897. 

" On the Development of the Faculty of Speech." Inter- 
national Medical Magazine, July, 1903. 

Melville, N. J. " Standard Method of Testing Juvenile Men- 
tality by the Binet-Simon Scale." J. B. Lippincott Co., 
Philadelphia and London, 1917. t 

V Mogridge. " Alcoholism and Mental Deficiency." Journal of 
Psycho- A sthenics, June, 1904., p. 71. 

Murdoch, J. M. " Notes on the History of Five Microcephalic 
Y Children." Journal of Psycho-A sthenics, December, 1902, 

and March, 1903, vol. 7, Nos. 2-3. 

Pearce, Rankine and Ormond. "Notes on Twenty-eight Cases of 
Mongolian Imbeciles." British Medical Jour nal, July 23rd, 
1910. 

Petersen and Sachs. " Cerebral Palsies of Early Life." Journal 
of Nervous and Mental Disease, 1890, and July, 1898. 



ARTICLES 279 

Petersen. " Arrested Cerebral Development." Ibid., Septem 

ber, 1887 and 1892. 
Philippe, J., and Paul-Boncour, G. " Les Anomalies mentales 

chez les ecoliers." Paris : Balliere et Cie., 108 Boulevard 

Saint-Germain. 1905. 
Potts, W. A. " Mentally Deficient Children." Birmingham 

Medical Review, October, 1901. 
" The Recognition and Training of Congenital Mental 

Defectives." British Medical Journal, May 9th, 1908. 
Richardson, H. " The Etiology of Arrested Mental Develop- 
ment." Journal of Psycho- A sthenics, September, 1902. 
Sheffield, H. B. " Idiocy and Allied Mental Deficiencies in 

Early Childhood." 
Shuttleworth, G. E. " Clinical Lecture on Idiocy and 

Imbecility." British Medical Journal, January 30th, 1886. 
— " Slighter Mental Deficiency in Children." Ibid., October 

3rd, 1903. 
" The Differentiation of Mentally Deficient Children." 

Trans. Internat. Congress Sch. Hygiene, 1908, p. 742. 

Mongolian Imbecility." British Medical Journal, Sep- 



tember 11th, 1909. 
Sollier, P. " Psychologie de l'ldiot et de l'lmbecile." Paris, 

1891. 
Sucksland, O. " Die Mongoloide Idiotie." Thesis. Pritschow 

5, Bradenbergen Str., Halle a.S. 
Sullivan, W. C. ..." " Feebleminded and Measurement by Binet- 

Simon Tests." Lancet, March 23rd, 1912, p. 777. 
Taylor, J. M., and Pearce, F. S. " Heart and Circulation in the 

Feebleminded." Journal of Psycho- Asthenics, Sept., 1902. 
Thomas, C. J. " The Aphasias of Childhood and Educational 

Hygiene." Public Health, May, 1908. 
Thomson, John. " Congenital Mental Defect (Amentia) in 

Childhood"; also in "Diseases of Children." Garrod, 

Bolton and Thursfield. Arnold, London, 1913. 
Tredgold, A. F. " Amentia." Practitioner, September, 1908. 

" Special Training considered from a Physiological Stand- 
point." British Journal Children's Disease, October, 1905. 

" A Clinical Lecture on Feebleminded Children." The 



Medical Press, August 25th and September 1st, 1909. 
Warner, F. " Report on Physical and Mental Condition of 

50,000 School Children." Parke's Museum, 1892. 
" Report on the Scientific Study of the Mental and 

Physical Conditions of Childhood." London, 1895, Royal 

Sanitary Institute. 
_ » A Study of Children." London, 1897, 



280 BIBLIOGRAPHY 

Wilhete, O. C. " Report on Pathological Work at the Iowa 

Institute for Feebleminded Children." Journal of Psycho- 

Asthenics, September, 1902. 
Wilmarth, A. W. " Report on the Examination of 100 Brains 

of Feebleminded Children." Alienist and Neurologist, Oct., 

1890. 
Wilson, S. A. K. "A Review of the Question of Aphasia." 

Review of Neurol., and Psychol., July, 1909, p. 151. 



B. Heredity and Inherited Factors 
Text Books marked *. 

*Ballantyne, J. W. " Antenatal Pathology and Hygiene." 
Edinburgh: Messrs Green & Sons, 1902 and 1904. 

Bateson, W. " Materials for the Study of Variation." London. 

*Darwin, C. " The Origin of Species." " The Descent of 
Man." Murray, London. 

Elderton, E. M., and Pearson, K. " A first Study of the 
Influence of Parental Alcoholism on the Physique and Ability 
of the Offspring." Memoir X of the Eugenics Laboratory 
Memoirs. Dulau & Co., London, 1910. 

Galton. " Natural Inheritance." Macmillan, London, pp. 259. 

Goddard, H. H. " The Kallikak Family." Macmillan Co., New 
York, 1912. See also " The Archives of Pediatrics, Septem- 
ber, 1912, p. 641. 

*Herbert, S. " The First Principles of Heredity." London : 
Adam and Charles Black. 1910. 

Huth. " Consanguineous Marriage and Deaf-Mutism." Lancet, 
February 10th, 1900, p. 367. 

*Lock, R. H. " Recent Progress in the Study of Variation, 
Heredity, and Evolution." Murray, London, 1906. 

MacMurchy, Helen. 1914 and 1915. " Feebleminded in 
Ontario." L. K. Cameron, Toronto. 

Mendel, G. J. " Versuche uber Pflanzen Hybriden." English 
Translation (Bateson). Journal R. Horticultural Soc, 
xxvi., 1901. 

Mott, F. W. " The Nervous System in Chronic Alcoholism." 
British Medical Journal, November 5th, 1910. 

Pearson, Karl. " Numerous Writings on Heredity and 
Biometry." Biometrika and other Journals. 

Potts, W. A., and Others. " The Relation of Alcohol to Feeble- 
mindedness." British Journal of Inebriety, vol. vi, No. 3. 



LEGAL BOOKS 281 

Punnett, R. C. " Mendelisin." Cambridge. Second Edition, 

1907. 
" Discussion on Heredity and Disease." Proceedings of 

the Royal Society of Medicine. 
*Reid, G. A. " The Laws of Heredity." London : Methuen 

and Co., 1910. 
♦Thomson, J. A. " Heredity." London : Murray, 1908. 
Weidersheim. " The Structure of Man." Translation by 

Barnard. 
Weismann, A. " The Evolution Theory." Translation by J. A. 

and M. R. Thomson, London. 

C. Legal Books. 

Davey, H. " The Law Relating to the Mentally Defective." 
Stevens & Sons, Ltd., 119 and 120 Chancery Lane, London. 
Second Edition. 1914. 

Wormald, J. and S. " A Guide to the Mental Deficiency Act, 
1913." P. S. King & Son, Orchard House, Westminster. 

Acts, Reports, Publications. 

The following may be useful for reference : — 
Acts, Regulations, etc., such as : — (1) Mental Deficiency Act, 

1913, pp. 43, 4£d. ; (2) Provisional Regulations, Secretary 
of State for the Home Department, 1914 (178), pp. 66, 3£d. ; 
(3) Statutory Rules and Orders, 1915, regarding the Transfer 
of Patients (975), pp. 2, Id.; (4) Elementary Education (De- 
fective and Epileptic Children) Act, 1899, pp. 6, Id.; (5) 
Elementary Education (Defective and Epileptic Children) Act, 

1914, pp. 5, Id. ; (6) Board of Education Regulations, etc. 
Conference on the Administration of the Mental Deficiency Act, 

1913. Central Association for the Care of the Mentally 
Defective. February 5th, 1918. 

Reports Annual of the Inspector of Auxiliary Classes of Ontario. 
A. T. Wilgress, Toronto. Reports Annual of the Feeble- 
minded in Ontario. Dr. Helen MacMurchy. 

Reports Annual of the Trustees of the Massachusetts School for 
the Feebleminded at Waltham. Wright & Potter Printing 
Co., 32 Derne Street, Boston.. 

Reports Annual. Central Association for the care of the Mentally 
Defective. 

Report of the Special Schools After-Care Sub-Committee. Educa- 
tion Committee, Birmingham, 25th June, 1915. Percival 
Jones Ltd., Birmingham. 



282 BIBLIOGRAPHY 

Report of the Commission for Investigation of White Slave 
Traffic, so-called. Wright & Potter, 32 Derne Street, Boston, 
1914. 

Report of the Royal Commission for the Care and Control of 
the Feebleminded, 1908, vols, i to viii. " The Problem of 
the Feebleminded." 1909. P. S. King, London, 1/- net. 
Abstract of the above report. 

Reports Annual of the Chief Medical Officer of the Board of 
Education for 1912-1919. Wyman, London. 2/6 net. 

Report of the Departmental Committee on Defective and Epilep- 
tic Children, 1898, vol. i. Report, vol. ii, Evidence, Appen- 
dices, etc. Wyman & Sons, London. 2/3. 

Reports Annual of the Board of Control. " Lunacy and Mental 
Deficiency." Wyman & Sons, Ltd., Fetter Lane, London, 
E.C.4. 

Reports on Suggestions for School Organisation and Classification 
in Institutions for the Mentally Defective. Board of Control, 
66 Victoria Street, S.W. 

The Annual Charities' Register and Digest. London, 1910. 
Longmans, Green & Co. This contains a list of homes for 
feebleminded children, as also does the Medical Directory. 
London : J. and A. Churchill. 

Report of the Royal Commission on the Care and Control of the 
Feebleminded. 1908. London : Wyman & Sons. Vol. viii 
contains the final report. Price 4/4. 

Reports of the Lancashire and Cheshire Society for the Perma- 
nent Care of the Feebleminded. 1899-1919. Manchester: 
Rawson & Sons, New Brown Street. 

Report of the Royal Commission on Physical Training in Scot- 
land. Edinburgh, 1903. 

Report of the Royal Commission on the Blind, Deaf and Dumb. 
Wyman & Sons, London, 1889. 



Periodicals. 

The Training School Bulletin, New Jersey, U.S.A. The Training 

School, Vineland, Monthly. 
Education Handwork, Pitman, London. Monthly, 2d. 
The Journal of Psycho- A sthenics, Faribault, Minnesota, U.S.A. 

Published Quarterly. (Dr. A. C. Rogers.) 
School Hygiene, Monthly. Adlard & Son, Bartholomew Close, 

London, E.C. 



GLOSSARY 



Amentia. — A term synonymous 
with Mental Deficiency. 

Aphasia. — Loss or defect of 
power of speech or writing. 
This may be of two kinds : 

(1) Sensory, when there is 
inability to remember or to 
comprehend words ; and 

(2) Motor, when there is 
inability to articulate 
words. 

Asexualization. — See Surgical 
Sterilization. 

Ateleiosis. — A condition re- 
sembling continued youth. 

Backwardness. — A condition 
in which mental develop- 
ment is retarded through 
disease, sense-deprivation, 
or some other adverse con- 
dition; if suitable treat- 
ment can be adopted the 
child improves and be- 
comes mentally normal. 

Biochemistry. — The chemistry 
of living tissue. 

Biometry. — A term applied to 
the study of Heredity by 
statistical methods. 

Bulimia. — Insatiable desire for 
food. 

Cerebral Diplegia. — One of the 
special types of mental 
deficiency, where there is 
accompanying physical de- 
formity. See Chap. VI. 

Cerebrum and Cerebellum. — 
The upper larger portion 
of the brain and the under 
smaller portion respec- 
tively. 

283 



The cerebrum is the most 
important part, and the 
cerebellum has to do with 
balancing and co-ordina- 
tion. The cortex cerebri is 
the external layer of the 
cerebrum. . 

Chromatin. — The granular 
deeply staining part of a 
cell-nucleus. Chromosomes 
are the rod-shaped bodies 
formed by the chromatin 
when cell-division is about 
to take place. 

Cirrhosis. — Liver disease often 
due to prolonged taking of 
alcohol in excess. 

Cortex. — See Cerebrum. 

Craniectomy. — The operation of 
partial excision of the 
bones of the skull to allow 
of their opening out if 
necessary. 

Cretinism. — A condition identi- 
cal with myxoedema, due 
to absence of the thyroid 
gland in the neck. See 
Chapter VI. 

Cyrtometer. — A leaden instru- 
ment for taking contours. 

Cytology. — The branch of 
science treating of cells. 

Deaf-mutism. — A condition of 
being both deaf and dumb. 
It may be congenital in 
origin, but is more com- 
monly due to deafness from 
disease in early infancy or 
early childhood. 

Diplegia. — Paralysis on both 
sides of the body. 



284 



GLOSSARY 



Diplococcus Intracellularis. — A 
germ which causes mening- 
itis. 

Encephalitis. — Inflammation of 
the brain substance. 

Enuresis. — Incontinence of 
urine, which is most com- 
monly nocturnal though it 
may be diurnal as well. 

Epicanthus. — A projection of a 
fold of skin over the inner 
canthus of the eye. 

Epilepsy. — A disease charac- 
terised by convulsions 
which are accompanied 
with loss of consciousness. 
There are two forms : (1) 
Grand Mai or Major 
Epilepsy, in which the fits 
are marked and of con- 
siderable duration ; and 
(2) Petit Mai or Minor 
Epilepsy, in which the fits 
are slight and sometimes 
barely noticeable. In true 
epilepsy the brain does not 
show any actual signs of 
disease, but in other forms 
there may be meningitis or 
scar-tissue in the brain, 
and then the fits are gene- 
rally worse and do not re- 
act to treatment as readily 
as do true epileptic fits. 
Epileptic fits may be a 
cause of incontinence of 
urine or fasces. 

Eugenics. — The study of agen- 
cies which are under social 
control and which may im- 
prove or impair the racial 
qualities of future genera- 
tions either physically or 
mentally. 

Feeblemindedness. — The high- 
est grade of Mental Defi- 
ciency. 

Fertilization. — The impregna- 
tion of the ovum with the 
spermatozoon . 

Follicular Tonsillitis. — An in- 



flammation of the tonsils, 
which may spread from one 
child to another and is not 
diphtheritic in nature. 
Fontanelle. — The gaps left be- 
tween the bones of the 
skull in early life. These 
are closed by union of the 
bones, and the largest, the 
anterior, does not close un- 
til about eighteen months. 
Gastric. — Relating to the 
stomach. 

Genetous. — A term used in 
connection with mental de- 
fect and signifying that 
that defect is inherited. 

Gestation. — Pregnancy. 

Hsemoptysis. — Hasmorrhage or 
bleeding from the lungs, a 
symptom of consumption. 

Hemiplegia. — Paralysis or 
weakness of one side of 
the body, often due to an 
effusion of blood on to the 
brain on the opposite side 
to that which is paralysed. 

Hydrocephalus. — " Water on 
the brain." Fluid collects 
inside the skull and com- 
presses the brain. The 
condition may be congeni- 
tal or the result of mening- 
itis. See Chapter VI. 

Hypotonia. — Laxity or want 
of tone as applied to 
muscles or ligaments. 

Idiocy. — The lowest grade of 
Mental Deficiency. 

Idiots Savants. — Mentally defi- 
cient persons who are ex- 
ceptionally gifted in one 
especial faculty. 

Imbecility. — The medium grade 
of Mental Deficiency. 

Immunity. — The state of being 
immune or exempt from a 
disease. Immunity may 
be (1) inherited and innate 
or (2) acquired as the re- 
sult of an attack of the 



GLOSSARY 



285 



disease. (An attack of 
Scarlet Fever confers im- 
munity to future attacks.) 

Incubation Period. — The period 
between infection and the 
first appearance of symp- 
toms. 

Insanity. — Disorder of the 
mental faculties developing 
at some period of life. 

Labials. — Consonants pronoun- 
ced by the lips. 

Lolling . — Defective articula- 
tion of the consonants. 

Larynx and Laryngeal. — The 
larynx is the upper and 
expanded part of the wind- 
pipe, and contains the vocal 
cords. 

Linguals. — Consonants pro- 
nounced by the aid of the 
tongue. 

Lobule. — The fleshy dependent 
part of the ear. 

Lunatic. — One who has become 
insane. 

Malaise . — Indisposition . 

Melancholia. — A form of in- 
sanity, characterised by 
extreme mental depression. 

Mendelism. — Mendel's theory 
of heredity, embracing the 
idea of unit characters and 
of dominance and latency 
of these. 

Meningitis. — Inflammation of 
the membrane surrounding 
the brain. It may follow 
pneumonia, tuberculosis, 
ear disease, syphilis, or in- 
fection with meningococ- 
cus. 

Mental Deficiency. — A term 
synonymous with amentia, 
signifying imperfect de- 
velopment of the mental 
faculties and due to an in- 
complete and irregular de- 
velopment of the nerve 
cells in the brain. 

Microcephaly. — Mental defi- 



ciency accompanied by a 
very small brain and head. 
See Chapter VI. 

Miliary Tuberculosis. — Tuber- 
culosis generalised and 
spreading all over the body 
by the blood stream. 

Modifications. — Variations ac- 
quired during the lifetime 
of the individual. 

Mongolism. — A special type of 
Mental Deficiency, so- 
called because cases be- 
longing to it resemble the 
Mongolian race in features. 

Moron. — A term used in 
America to designate the 
highest grade of mental 
defectives, i.e., the feeble- 
minded. 

Morphological. — Having to do 
with the structure and 
form of organisms. 

Mutation. — A process by which 
new parts arise in an indi- 
vidual by a sudden varia- 
tion. See page 164. 

Myxcedema. — See Cretinism. 

Natal. — Having to do with 
birth. 

Natural Criminals (Moral De- 
fectives). — Persons who, 
though usually of good 
mental powers, have some 
innate defect that makes 
them liable to various 
forms of wrongdoing. 
Training cannot eradicate 
this defect. 

Natural Selection. — One of the 
great theories of heredity. 
See page 164. 

Nerve Cell, Neuroglia, Neu- 
ron. — The brain is made 
up of nerve cells em- 
bedded in and supported 
by the neuroglia. The 
nerve cells are the essen- 
tial part of the brain, and 
send out processes by 
which they communicate 



286 



GLOSSARY 



with the various parts of 
the brain and body. The 
main branch of each nerve 
cell forms a neuron. 
Nerve cells may be motor, 
causing movement, or sen- 
sory, i.e., connected with 
sensation and mental pro- 



Neuropathic. — Relating to or 
affected with nervous 
disease. 

Neuropathic Diathesis. — Con- 
stitutional predisposition 
to nervous disease. 

Neuropathic Inheritance. — In- 
herited predisposition to 
nervous disease. 

Neurosis. — A nervous disease 
in which, as in Hysteria, 
there is no actual visible 
alteration in the nervous 
system. 

Nucleus. — The spherical body 
within a cell; it takes an 
essential part in reproduc- 
tion. 

Nurture. — Nourishment and 
care which often enable 
helpless and weakly indi- 
viduals to survive. 

Nystagmus. — Continuous trem- 
bling movement of the 
eyeball, especially evident 
in looking to the side. 

Occipital. — Pertaining to the 
back of the head. 

Ovum. The female reproduc- 
tive cell. 

Oxycephaly ("Steeple Skull"). 
— A condition in which the 
skull is very high and the 
frontal and occipital bones 
sloping away to a cone-like 
top. Often the eyes are 
very prominent in this con- 
dition. 

Palpebral. — Relating to the 
eyelid. 

Parietal. — Pertaining to the 
side of the head. 



Parotid Gland. — One of the 
glands supplying saliva 
and situated just behind 
the angle of the lower jaw. 
This gland is inflamed and 
swollen in Mumps. 

Parrot-Speech. — The senseless 
repetition of sentences or 
words heard. 

Pathology. — The study of 
diseased organs. 

Pediculi. — Lice on the head; 
they lay eggs as nits on 
the hair and these hatch 
out at intervals. Oil of 
Sassafras is the best 
remedy for the condition. 

Placenta. — The fleshy mass, 
which forms the after- 
birth, and acts as a 
medium between mother 
and child whilst the child 
is in utero. 

Plasm, Protoplasm. — There are 
two plasms, the germinal 
or reproductive, and the 
somatic or tissue building. 
See page 161. 

Phthisis. — A wasting away. 
Phthisis is now used to 
designate tuberculosis of 
the lungs. 

Pica. — The habit of eating 
dirty and unnatural things. 

Pinna. — The external ear deve- 
loped from six parts — the 
helix, crus helicis, anti- 
helix, tragus, anti-tragus, 
and lobule. See Plate IV. 

Pituitary Body. — A small part 
of the brain under the 
cerebrum. 

Progeria. — A condition re- 
sembling premature old 
age. > 

Prognathism. — Projection of 
the jaw. 

Prognosis. — Prediction of pro- 
gress or termination. 

Protoplasm. — The viscid matter 
composing a living cell. 



GLOSSARY 



287 



Pseudo-hypertrophic Muscular 
Paralysis. — A progressive 
disease of the muscles 
leading to complete para- 
lysis and death. There is 
a deceptive increase in size 
of the muscles at first, and 
the calves of the leg show 
this the most. 

Pulmonary. — Referring to the 
lungs. 

Quarantine. — The period dur- 
ing which the child, who 
has been exposed to infec- 
tion, may develop the 
disease and therefore 
should be kept from con- 
tact with other children, 
who have not been exposed 
to infection. 

Regression. — The tendency to 
return towards mediocrity. 
Filial regression is the 
general tendency to return 
to mediocrity shown by 
the children of gifted 
parents. 

Reversion. — A condition in 
which individuals exhibit 
ancestral traits, which their 
immediate parents did not 
possess. 

Rickets. — A disease of infancy 
and early childhood, caused 
by bad food and bad sur- 
roundings. It leads to 
anaemia and bony defor- 
mities and often causes 
backwardness. 

Scabies. — A skin disease due 
to the itch mite, which 
most commonly lodges in 
the skin between the 
knuckles. Sulphur oint- 
ment is the best remedy. 

Sclerosis. — Thickening and 
contraction as a result of 
scar tissue. 

Segregation. — The separation 
of any class of individuals 
from the remainder of the 



community. Also used to 
denote the process by 
which characters are sifted 
or bred out. 

Sense-deprivation. — Deafness or 
blindness or similar condi- 
tions caused by the loss of 
a sense, usually caused by 
disease. 

Spasticity. — A weakness or 
paralysis of the limbs 
characterised by stiffness 
and jerkiness and contrac- 
tures. 

Spermatozoon. — The male re- 
productive cell. 

Sports. — See mutation. 

Sterilization Surgical. — An 
operation which renders 
procreation impossible. 

Stigmata of Degeneration. — 
Physical or mental defects 
exhibited by persons of 
the neuropathic type. 

Strabismus. — Squint. 

Synostosis. — A joining of 
bones. 

Thyroid Gland. — A gland that 
is situated at the junction 
of the neck with the front 
of the chest; it is absent 
in Cretinism. 

Tragus. — The projecting part 
of the external ear in front 
of the opening. 

Tuberculosis. — A disease other- 
wise known as consump- 
tion, which is due to a 
germ and may affect any 
part of the body. The 
germ may spread because 
it is coughed up and, after 
the sputum has dried, 
blown about, or because it 
is present in meat or milk 
or other foods. 

Variations. — A term used in 
dealing with heredity to 
denote the way in which 
offspring differ from their 
parents. 



INDEX 



Aberdeen, Reports on, 65. 

Abnormal Conditions of Mother, 
189; of foetus, 189. 

Abnormalities, gross, 173; ner- 
vous, 184. 

Aboriginal, 176. 

Abscess, 189. 

Abstract Ideas, 73 87. 

Accidental Feeblemindedness, 
12, 55. (See Acquired). 

Accommodation for Mental De- 
fectives, 46; insufficient, 4. 

Acne, 121. 

Acquired Characters not trans- 
mitted, 162; causes, 189- 
196; factors, 189-196; table 
of, 189 ; feeblemindedness, 
55, 109. 

Acts, Education, 4, 5, 6; and 
Reports, 281 ; Inebriates, 
18; Idiots, 1, 21; Lunacy, 
1, 24; Mental Deficiency, 
23, 24, 27 ; Elementary Edu- 
cation, 5, 23. 

Addresses of Associations, 268; 
of Societies, 268. 

Adenoids, 150. 

Adenoma Sebaceum, 68. 

Adherent Epicanthic Folds, 62. 

Admission to Institutions, 27, 
143; to Schools, 115, 208, 
209. 

Adoption by Guardians, 38. 

Adults, defective, 40; supervi- 
sion, 45. 



After-care, Associations, 32; in 
Birmingham, 199; Commit- 
tees, 36 ; Measures, 44. 

Ages of Parents, effect of, 102, 
179, 187, 192; on admission, 
27 et seq. ; on discharge, 
8, for training, 52. 

Alcohol, 18; family history of, 
116; as inherited cause, 
179 ; effect on tainted stock, 
18, 183; avoid in diet, 210; 
during pregnancy, 184; and 
illegitimacy, 18. 

Alcoholic cirrhotic disease, 183. 

Alcoholism, history of, 119; 
also, 182, 189; definition, 
182. 

Alderley Edge, 244. 

Allbutt, Sir Clifford, 12. 

Allen, A. A., 16. 

Alphabet, physiological, 94, 250. 

Ament, definition of, 10. (See 
also Mental Defectives). 

Amentia, 12. (See Mental Defi- 
ciency). 

American Institutions, 9, 117; 
methods, 42 ; States, 
efforts, 181. 

Anaemia, 185, 195. 

Ancestral Inheritance, 166 

Animals, liking for, 87; imi- 
tate, 105; mentally defi- 
cient, 176. 

Ante-natal life, 189; acquired 
factors, 189. 

Antero-posterior diameter, 61. 

Anti-helix, 61. 



289 



290 



INDEX 



Antitragus, 61. 

Apathy of brain, 73, 100. 

Aphasia, 283. 

Apparatus, hearing, sight, 
touch, 70, 71, 89; of 
speech, 90. 

Appearance, general, 123, 126, 
141. 

Appendices, 207-282. 

Approved Homes and Certified 
Houses, 42, 259. 

Aprons, 216, 225. 

Arc of skull, 247. 

Areas of brain, 72. (See Dia- 
gram VI.) 

Arithmetic, 86. 

Articles, list of, 275. 

Asexualisation, 203. 

Ascertainment of cases, 49. 

Ashby, Dr. Henry, 7, 12, 16, 
58, 88, 193, 244. 

Asphyxia neonatorum, 192. 

Associations, addresses of, 268; 
Central, 33; for After- 
care, 32; voluntary, 33, 36; 
of Education Committees, 
33; of Poor Law Unions, 
33. 

Association paths, in brain, 70; 
paths, 88; testing of, 124; 
development of, 167 et 
seq.; fibres, 77, 78, 171; 
and ideation, 77. 

Asylums, 2, 3; idiot, 2; Star- 
cross, 3; Earlswood, 3; 
Royal Albert, 3; Colches- 
ter, 3; Commissions report 
on object of, 2, 3; returns 
from, 19; list of, 259 et 
seq. ; Boards Metropolitan 
and Lancashire, 33. 

Asymmetry of skull, 58, 121. 

Ateleiosis, 114. 

Athetosis, 111. 

Attendants, at meals, 213; 
concerned with the care of 
Mental Defectives, 34 ; 
outdoor, 234; men, 233, 
234, 243. 

Attention, 71, 73, 119, 123, 126, 



142; Individual, 232; Nat- 
ural or spontaneous, 73 ; 
Voluntary or established, 
73. 

Auditory sensations, 77; paths, 
77; area, 90. 

Authorities, Local, 23, 24 et 
seq., 50; Central, 23; 
Judicial, 51 ; Duties, 48. 
Education, 4, 28. 

Average mean, 164. 



B 



Babbling, 92, 124. 

Backward Children, 28, 115. 

Backwardness, 125, 126; Dif- 
ferential diagnosis of, 125, 
126; Cases of, 126. 

Balance, 68 ; Defects of, 123. 

Ball games, 239. 

Ballantyne, Dr., 167, 168, 175, 
180. 

Barr, Dr., 135, 136, 183. 

Basion, 61. 

Bath, Marquis of, 8. 

Bathing, 153; Method of, 209. 

Baths, 209 ; temperature of, 209 ; 
frequency of, 220; rooms, 
219. 

Beach, Dr., 183. 

Beans and Boston receipt, 211. 

Bearing, general, 123. 

Bed, 150, 217; wetting, 150, 
217 (see Enuresis); clothes, 
not over head, 219; making 
of, 218. 

Behaviour, 141. 

Belladonna, 150. 

Benington, Miss Helen, 19. 

Bibliography, 275. 

Binet and Simon, Tests, 124, 
130, 131, 283, 253. 

Biochemistry, 283. 

Biometry, 166. 

Biparental reproduction, 161. 

Birdwitted, 73. 

Birmingham, after-care, 199 ; 
proportion of feebleminded, 



INDEX 



201 



14 ; Education Committee, 
9. 

Birth, injuries at, 118; difficul- 
ties at, 118, 193; (see also 
Natal). 

Bitragal Arc, 61 ; diameter, 61, 
247. 

Bladder, defective control over, 
68, 84, 150. 

Blankets, 217. 

Blind, 21, 29. 

Blindness, 70, 112, 194. (See 
Eye). 

Blood, influences through 
mother, 167; course in 
foetus, 167, 169; vessels, 
rupture of, 170; effect of 
poorness of, 195. 

Blood relations, 179; and mar- 
riage, 202. 

Board test, 124, 130. 

Board of Control, 23, 35; of 
Education, 28, 149, and re- 
gulations, 227 ; address, 
269; Board of Guardians, 
38. 

Boarding out, 199. 

Body, cells, 161; plasm, 161; 
external paths, 71. 

Boils, 160; and persistence of, 

160. (See Furunculosis). 

Bolsters, 217. 

Bolt food, 212. 

Bolton, Dr., 171. 

Bolton Education Committee, 
12. 

Bolton sheeting, 217. 

Books, List of, 275. 

Boots, 197, 225 ; and lacing, 230. 

Borax in epilepsy, 152. 

Borderline cases, 115. 

Boston receipt, 211. 

Bourneville, Dr., 183. 

Bowels, control of, 68, 84, 150, 
219. 

Brackenbury, Dr. H. B., 50. 

Brain, conditions in feeblemind- 
edness, 101, 103, 171 ; ways 
into, 90 ; ways out of, 91 ; 
development, 70, 169; for- 



mation of, 169; compared 
to community, 172; ner- 
vous control of, 89; disease 
of, 170, 189, 195, and as a 
cause, 195; at birth, 169; 
weight of, 169; injuries of, 
170; nerve cells of, 170; 
intellectual faculties of, 
171 ; of lunatics, 171 ; and 
under-development, 171 ; 
and innate power to develop, 
171 ; of embryo, 170. (See 
also 167-177). 

Brain cells, arrangement of, 
171 ; pigmentation of, 171 ; 
gaps in, 172; immaturity 
of, 172. 

Branthwaite, Dr., 18. 

Breakages, 227. 

Breakfast, 211. 

Breeding out of taint, 203; of 
characters, 165. 

Brentry Reformatory, 9. (See 
Fleck, Dr.) 

Bricks, 228. 

British Association for the Ad- 
vancement of Science, 5; 
Journal of Inebriety, 182 ; 
Medical Association, 5. 

Bromides, 152. 

Broncho-pneumonia, 105. 

Brook House, 244. 

Broth, 211. 

Brushes, care of, 221. 

Bruit of heart, 104. 

Building plans of Wyatt House, 
270 and 271. 

Bulimia, 141. 

Burden, Rev. H. N., 9. 

Burgwin, Mrs., 6. 

Byrne, Sir W., 9, 33. 



Caldecott, Dr., 19, 136. 
Calculation, 86; power of, 119, 

127. 
Callipers, 247. 



292 



INDEX 



Callousness, 76. 

Cancer, 188. 

Capacity, cranial, 59. 

Caps, 215. 

Capes, 215. 

Carbolic Acid, 156. 

Cardiac dullness, 104. 

Care* of animals, 146; as pre- 
ventative, 136; and control, 
1, 7, 20, 34, 39; and treat- 
ment, 145-161 ; (see also 
Lifelong and Permanent); 
of eyes, ears, teeth, nose, 
throat, 149. 

Carriage, general, 68, 119; de- 
fects of, 123. 

Cases, of speech defect, 253; 
of backwardness, 126, 128, 
132; of microcephaly, 106; 
of hysteria, 152; of Mon- 
gols, 101 ; of paralytic, 111 ; 
of cretinism, 139; in in- 
fancy, 128 ; of mental defect 
in early life, 133; of pica, 
141 ; of eating from dust- 
bin, 84; attracted by jing- 
ling coins, 73; primary and^ 
secondary, 55 ; accidental, 
55; acquired, 55; case 
sheets, 116. 

Cataract, 104. 

Causation, 9, 12, 173, 178-196; 
and heredity, 13; of speech 
defect, 90. 

Causes, post-natal, 193; in- 
herited, 178-188; acquired, 
189-196. (See Factors). 

Cavendish, Lady Frederick, 7. 

Cavities in brain, 113. 

Cells, reproduction and here- 
dity, 161-166. 

Census, 186. 

Central, authority ^ 23 ; Associa- 
tion, 33; (see Fox, Miss 
E.); powers in brain, 70, 
90; and speech, 91; central 
defects, 91. 

Cerebral, Diplegic, 99, 109; 
Hemiplegic, 99, 109, 139. 

Cerebrum, Cerebellum, 283. 



Certificates and Forms, 255- 
259. 

Certificate, Government, 255. 

Certified Houses and Approved 
Homes,. 41, 42, 259. 

Certifying Officers, courses open 
to, 199. 

Chadwick-Healey, C. E. H., 
K.C., 9. 

Character, Lifelong, 11. 

Characteristics, general, 64 ; 
physical, 55-69 ; classifica- 
tion, 55; table of, 57; of 
infectious diseases, 156. 

Charity Organisation Society, 
5, 33; Charitable Institu- 
tions, 10. 

Chickenpox, 160. 

Chilblains, 65, 153. 

Children, number of mentally 
defective, 14 ; of two feeble- 
minded parents, 175. 

Chloride of Lime, 156. 

Chocolate, 212. 

Chromatin, Chromosomes, 283. 

Chronicle, Medical, 247. 

Church Pentientiary Associa- 
tion, 19. 

Circulation, 65, 153. 

Circumference of Head, 58, 
118; normal, 58; smallness 
of, 58. 

Cirrhosis of the liver, 183. 

Clare, Sir Harcourt, 46, 50. 

Clark, 135, 136. 

Classification of Mental Defec- 
tives, 10; of cases, 55. 

Cleanliness, 84, 142. 

Cleft palate, 64, 65. 

Cloak-rooms, 155. 

Clogs, 215. 

Closets. (See Offices). 

Clothes, 196 ; quantity of, 65 ; 
tightness of, 215; care of, 
215, 216, 236; lice in, 209; 
on admission, 209; reserve 
of, 225; making of, 196. 

Clouston, Sir T., 16, 19. 

Clumsiness, 237. 

Coats, over, 215. 



INDEX 



293 



Cocoa, 211. 

God Liver Oil, 214. 

Coffee, 210. 

Cold, bad effect on, 214. 

Colchester Asylum, 3. 

Cole, Mr., 47. 

Collars, 216. 

Colonies, 43, 45; list of, 259 et 
seq. ; best for life-long 
care, 199. 

Colours, 122, 251; Colour- 
blindness, 122. 

Combs, care of, 221. 

Commission, Blind and Dumb, 
report of, 4; Royal, on 
care and control of Feeble- 
minded, 1 et seq. 

Commissioners, 13, 23. (See 
Causation). 

Committee, Joint, of British 
Medical Association, etc., 
5; Local, 23, 50; Depart- 
mental, on Defective and 
Epileptic Children, 6; also, 
26. 

Companionship, value of, 232. 

Conception, 161, 178; life his- 
tory after, 167; inherited 
causes before, 178. 

Conclusions, as to mental de- 
fect, 173; re conditions of 
brain in feeblemindedness, 
174; as to inherited causes, 
188; as to alcoholism dur- 
ing pregnancy, 188; as to 
acquired causes, 195 ; as to 
cause of speech defects, 88. 

Condition of brain in feeble- 
mindedness, 101, 103, 171. 

Conference. (See Guildhall, 
46). 

Congenital, feeblemindedness, 
13; origin, 64; abnormali- 
ties, 65; deafness, 70. 

Conjunctiva, 63; Conjunctivitis, 
158. 

Consanguinity, 179, 187. 

Conscience, 80. 

Consonants, defective pronun- 
ciation of, 89, 92. 



Constipation, 100, 108, 152. 

Consumption, 116. (See Tuber- 
culosis). 

Continuity of germ-plasm, 161, 
174. 

Contours of heads, 58. 

Contractures in paralytic cases, 
110, 111. 

Control, defective, 68; of blad- 
der and bowels, 68, 84, 150; 
of muscles, 123; age at 
which acquired, 118. 

Convalescence, 156. 

Conversation at meals, 212. 

Convulsions, of brain, 102; 
also 108, 116; (Inward C. 
116); also 189; description 
of, 193. (See Epilepsy). 

Cooking, need of good, 212. 

Co-ordination, 92. 

Corduroy, 215. 

Corsets, 216. 

Cortex, 102. 

Cost, of scheme for care, 45; 
of maintenance, 45. 

County Councils Association, 
33. 

Coupland, Dr., 47. 

Courses, for putting under 
care, 199; open to parents, 
199. 

Cowper, quotation from, 87. 

Cranial capacitv, 59. (See 
Skull). 

Craniectomy, 108. 

Creasol, 156. 

Cretin, 55-57, 99, 189, 193; (see 
Myxoedema) ; Prognosis, 
100; cases of, 139; treat- 
ment, 100 (see Plate VII). 
(See also Types). 

Crime and Mental Defect, 16. 

Criminal, responsibility, 17 ; 
propensities, 80, 197. 

Cruelty, 75. 

Cms helicis, 61. 

Cupboard for hearing, smell 
and touch tests, 229. 

Cups, 155, 226. 

Cyrtometer, 283. 



294 



INDEX 



Cures, 30. 
Cytology, 283. 



Dado, 216. 

Daily routine, 272. 

Dangerous cases, 199. 

Darenth Colony, 3. 

Darwin, theory of natural se- 
lection, 164; tubercle, 62. 

Day, rooms, furniture and floor 
of, 224; special schools, 143. 

Deaf, 29; (and Local Educa- 
tion Authorities). (See Ele- 
mentary Education Act). 
Mutism, 119; tests of, 122, 
123. Deafness, 6T, 112; 
and Meningitis, 112; con- 
genital, 70; and mental de- 
fect, 120, 129, 194; and 
tests, 130. 

Dean, Dr. H. R., 185. 

Death, incidence, 134; rates, 
134. (See Prognosis). 

Debilitating factors, 179. 

Decay of nerve-cells, 171. 

Decency, 219. (See Modesty). 

Decorations of rooms, 227. 

Defective, heads, 58; children, 
6, 8; Defectives, 30, 40; 
Double Defectives, 34. 

Definitions of mental defec- 
tives, 11. Also in Glossary. 

Degeneration, 63; of tissues, 
68; early, 68; stigma of, 
63. (See Decay). 

Degradation if not cared for, 
204. (See Vice). 

Degrading influence on other 
persons, 137. 

Degree of Mental Deficiency. 
(See Norsworthy, 79). 

Dements, 10. (See also Luna- 
tic). Definition, 10. 

Dendy, Miss Mary, 7, 13, 16, 
35, 43; Appendix I. 207- 
246. 

Dental arch, 121. 



Dentition, fits at, 68. 

Departments in Institutions, 
43. 

Detailed examination of head, 
246-250. 

Determinants, 165 ; dominant 
and latent, 165. 

Development, 167 ; inherited 
power of, 65 ; period of, for 
walking and talking, 120; 
failure of, 174; of associa- 
tions in brain, 119; retard- 
ed mental, 11, 177; incom- 
pleteness of, 174, 177. 

Diagnosis, 115-133; Apparatus 
necessary for, 116, 117; 
differential between feeble- 
mindedness and backward- 
ness, 125 and 126. 

Diagram of Life Periods, 168. 

Diameters of skull, 247. 

Diathesis. (See Neuropathic, 
121). 

Dickenson, W. H., M.P. 9. 

Diet. (See Food, Feeding, 
Medical Officer, Doctor). 

Dietary, 211. 

Differential diagnosis of feeble- 
mindedness and backward- 
ness, 125. 

Digestion, 146, 151 ; Digestive 
System, 136. 

Dining, rooms, floor of, 224; 
furniture of, 223. 

Dinner, 211. 

Diphtheria, 157. 

Diplegia, 109. (See Cerebral). 

Diplococcus intracellularis, 112. 

Discipline, 81 ; in dormitories, 
217. (See Management). 

Disease, infectious, 156-160 ; 
natural selection to, 164, 
176, 285; vitiating, 179; 
maternal, during pregnancy, 
189; of brain as cause, 189. 

Disinfection, 155; Disinfec- 
tants, 156. 

Dispensary, 241. 

Disposition, unsocial, 240. 

Distance, feebleminded at a, 74. 



INDEX 



295 



Doctor. (See Medical Officer, 
29). 

Donkin, Dr. H. B., M.D., 9. 

Dormitories, 216; utensils in, 
217; windows in, 217; ven- 
tilation in, 217; discipline, 
217. 

Douching, 153. 

Douglas, Dr., 20. 

Down, Dr. Langdon, 100. 

Dress, for boys, 214; for girls, 
216; care of, 215 and 216; 
ability to, 126. 

Drill, 111, 148. 

Drink and Mental Defect, 18. 

Drunkard, 197. 

Ductless glands, 103. 

Dull child, 115. (See Back- 
ward). 

Dunlop, Dr. J. C, M.D., 9. 



Ear, 61, 77, 83; external, 61, 
121 ; disease, 83 ; testing of, 
122; defects of external, 61, 
121; care of, 149; sensa- 
tion, 77; imperfect develop- 
ment of hearing, 176; see 
also, 176. 

Earliest born in family, 181. 

Earlswood Asylum, 3, 19. 

Early age, control at, 198. 

Earning capacity, 199. 

Eating, 145, 212. 

Edinburgh, size of families in, 
reports on, 65; Royal E. 
Asylum, 19. 

Educable Children, 26. 

Education, Act and Mental De- 
fect, 4 (see Acts); impor- 
tance of, 203; Authorities, 
4, 23; of public opinion, 
199. 

Elderton, Miss, 183. 

Election to Asylums, 199. 

Elementary Education Act, 5, 
6, 23, 27 et seq. 



Embryo, 178, 190; causes act- 
ing on, 178; weakened, 190; 
diagram, 168. 
Emissive paths of bram, 70. 

Employment Bureau, 37. 

Enamel ware, 266. 

Encephalitis, 99, 112, 172, 189; 
as a cause of mental defi- 
ciency, 173, 195. 

Encouragement to work, 236, 
242. 

Enunciation, 232. 

Enuresis, 150, 218. (See Bed- 
wetting). 

Environment and heredity, 165; 
and mutation, 165. 

Epicanthic Folds, 103, 121. 

Epicanthus, 62, 63. (See Eye 
Deformities). 

Epilepsy, 68, 179, 189, 193; 
family history of, 119, 151, 
180; effect on prognosis 
136, 140; meningitis and, 
140; isolated fits, 68, 153; 
as cause of neuropathic in- 
heritance, 179; tendency to 
transmission, 179; and 
feeblemindedness, 140; and 
treatment, 152; and falls, 
151, 194; and hysteria, 151, 
180. (See Fits). 

Eruptions, 121. 

Errands, 123, 131. 

Eugenics, 183, 203; laboratory 
memoir, 191. 

Evolution and natural selec- 
tion, 183. 

Examination, of cases for care, 
53; apparatus needed for, 
116, 117; method of, 117, 
118. 

Experimental, evidence and 
alcohol, 191. 

Exposure of body, 219. 

Expression, 67, 123; defective, 
67. 

External auditory meatus, 58; 
ear, 61 ; paths of the body, 
71; stimuli, 127. 

Eye, 62; deformities connected 



296 



INDEX 



with, 62; rolling of, 104; 
care of, 149. (See Sight). 
(See Blindness). 
Eyelids, imperfect development 
of, 175. 



F 



Factors, inherited, 178-188; ac- 
quired, 189-196 ; causative, 
179. 

Faecal incontinence, 219. (See 
Bowels) 

Faculties, 83. 

Failure of development, 174. 

Fall (see Injury); with epilep- 
tic fit, 151 ; and foetus, 190. 

Family history, 116, 118, 119; 
diagram of, 187; on form, 
118; see also 126, 180. 

Families, size of, containing 
feebleminded children, 201 ; 
prolificness of, 201. 

Farm work, 87, 197. 

Fatigue, 235. 

Fatness in girls, 65. (See 
Thyroid). 

Fatuous sounds, 128. 

Features, 99. 

Feeblemindedness, definition, 

I, 11; ratio in U.S.A., 177; 
spontaneous, 14; origin, 13; 
irregularity of 242; en- 
hanced by other factors, 
185; proportion, 14; in- 
nate, 13; see also, 1, 8. 
(See Mental Deficiency). 
Cases as illustrations, 126; 
not a reversion, 176; feeble- 
minded children, 6; defini- 
tion, 11 ; see also 115, 116 
et seq. Feebleminded 
parents, child of two, 161, 
175. Other feebleminded 
children in same family, 
201. Feebleminded persons, 

II, 14. 
Feeders, 213. 



Feeding self, 142. (See Diet). 

Felt for beds, 217. 

Fernald, Dr., 43, 76, 109, 124, 
135, 204, 228. 

Fertility of mentally deficient, 
13, 14. 

Fertilization, 284. 

Fevers, 112. 

Finance, 44, 46, 47. 

Finger, incurved little, 64, 
104, 121 ; imperfect devel- 
opment, 177. See also 65. 

Fires, 241; guards, 223, 226; 
in hospital, 241 ; exits in 
case of, 241. 

First born, 181. 

Fits, 68, 151. (See Epileptic). 
Hysterical, 68; and menin- 
gitis, 173. 

Flannel shirts, 214. 

Flannelette not good, 214. 

Fleck, Dr., 18. 

Fleming, B., 19. 

Foetal heart, 169. 

Foetus, 179; period, 190; death 
of in syphilis, 185; injury 
and disease of, 185; and 
shock, 190. 

Follicular tonsillitis, 158. 

Fontanelle, 106. 

Food, 210; bolting, 212. 

Forks, 212. 

Form for admission, 255-259; 
at Lancaster, 20. 

Formalin, 156. 

Formation, period of, 167. 

Formative processes, 169, 175; 
stigmata, 175 ; degeneration, 
175. 

Fox, Miss E., 49, 33. 

Fraenum linguae, 92. (See 
Tongue-tie). 

Fresh air, 155. 

Fright during pregnancy, 190. 

Frocks, 216. 

Frontal deficiency, 58, 67; 
association fibres, 77, 78, 
171. 

Fruit, 211. 

Fry, Sir Edward, 16. 



INDEX 



297 



Function, delayed development 

of, 128. 
Furniture, 223. 

Furunculosis, 160. (See Boils). 
Fusion of germ plasms, 162. 



Gait, 119. 

Galton, 166. 

Games, 65, 119, 239; organised 
value of, 232. 

Gardens, 239; as a cure for 
temper, 234. 

Gardening, 87. 

Garments, 214, 216. 

Gastric, 284. 

Genetous, 55. 

Genital organs in Mongols, 104. 

German measles, 157. 

Germ-plasm, 161, 162, 174; in- 
herited factors affecting, 
162, 179; action of syphilis 
on, 185; and deformities, 
162; and acquired charac- 
ters 162; toxic influences 
on, 164; and defect, 196. 

Gestation period, 179. 

Gifts, 224. 

Glossary, 283-288. 

Goddard, Dr., 87, 162, 163. 

Gordon, Dr., 185. 

Gowers, Dr., 180. 

Grace, 212. 

Grading of mental defect, 43, 
57. 

Grayson, Miss, 7. 

Greed, 212. 

Greene, H. D., M.D., 9. 

Grey matter of Drain, 112. 

Growth, 161, 167; inherited 
power of, 65. 

Guardians, 4, 34, 38; courses 
open to, 199; Board of, 21. 

Guardianship, of private indivi- 
duals, 38; in chosen cases, 
199. 

Guildhall Conference, 46. 

Guthrie, Dr., 97. 



H 



Habits, 84, 182; and prognosis, 
142. 

Habitual offenders, 82. 

Haemoptysis, 284. 

Haemorrhage, 109. 

Hair, cutting of, 209; care of, 
220. 

Hand movements, memory of, 
90. . 

Happiness, 195. 

Hardening measures, 153. 

Hare-lip, 65. 

Hay, Professor, 64. 

Head, defects of, 58 ; circumfer- 
ence of, 58, 247, 248; care 
of, 218, 220; contour meas- 
urements of, 58, 64, 247; in 
hydrocephalus, 58 ; detailed 
examination of, 246-250 ; 
asymmetry, 248; in micro- 
cephalus, 196; arcs of, 247; 
measurements of, 248; as 
stigmata, 248. 

Health, after asexualisation, 
203. 

Hearing, apparatus, 70; testing, 
119, 228; powers, 122; (see 
Ear); cupboard, 229. 

Heart, disease, 65, 153; organic, 
65; congenital, 104; incom- 
plete condition of, 102; 
and circulation, 153. 

Heights, 64, 105, 118, 121. 

Helix, 61. 

Heller, Dr., 86. 

Hemiatrophy, 173. 

Hemiplegia, 99, 109, 284; prog- 
nosis in, 139; and potato 
peeler, 226; case, 226. 

Heredity, 13, 161-166, 174; and 
causation, 13; taint in first- 
born, 181 ; text-books, list 
of, 280. 

History, on form, 118; personal, 
120; and prematurity, 193; 
and difficulties at birth, 193 
(See Family). 

Hitchen, Miss Scott's Home, 7. 



298 



INDEX 



Hobhouse, C. E. H., M.P., 9. 

Holland, Mr J. L., 50. 

Home, sickness, 80; treatment 
at, 146; results, 199. 

Homes, Rescue, 19; (see New- 
ark); Inebriate, 10; Ap- 
proved, 41 and 42. 

Horses, 233. 

Hospitals, 45; rooms, 240, 241; 
definition, 11 ; Pendlebury 
Children's, 56. 

House work, 245. 

Howe, Dr., 20. 

Huey, Dr., and mentality, 253. 
(See Binet-Simon). 

Hunter, Dr., 181. 

Hurle, Mrs, 46; and duties, 48. 

Hutchison, Dr., 202. 

Hydrocephalics, 55-57 ; (see 
Types); 99, 109, 113, 195; 
treatment, 113; (see Plate 
IX). 

Hygiene of schools, 148; men- 
tal, 43. 

Hypotonia of muscles, 102. 

Hysteria, 151, 179; case of, 
152; history of, 178, 180. 

Hysterical fits, 68, 151; treat- 
ment, 152. 



Ideation, 77. 

Idiot, definition, 1, 11 ; village, 
1 ; asylums, 2 and 10 ; 
savants, 74; lower than 
native, 176; also, 8, 10, 14, 
74, 115, 127. Idiots Act, 1, 
21. 

Ignorance of inheritance, 203. 

Illegitimacy; and mental defect, 
16, 18, 48, 187. 

Imagination, 78. 

Imbecile, definition, 1, 11, 14, 
74, 115, 127. (See Moral 
Imbecile, 11). (See Glos- 
sary, 284). 

Imitation, 142; in Mongols, 105; 
in Microcephalics, 108. 



Immaturity of nerve cells, 171. 

Immunity, 284; transmission of, 
to disease, 162. 

Impetigo, 160. 

Impressions in brain, 77; inter- 
pretation of, 92. 

Inborn variations, 163. 

Incontinence, 218. 

Incubation, 156. 

Incurvation of finger joint, 64. 

Individual teaching, 148, 232. 

Industrial school, 10; and 
system, 17. 

Inebriates, 18 ; and Act, 18 ; Re- 
formatory, Brentry, 9. 

Inebriety, British Journal of, 
182; Homes, 10. 

Inequality of mental defect, 
248. 

Infectious fevers, as causes, 189, 
194; case caused by, 195; 
description, 156 et seq.; 
diseases, 154. 

Infancy, mental defect in, 112; 
Mongolism, 104 ; cases of in, 
101, 102, 103. 

Inflammatory, 55-57; lesions, 
109. (See Meningitic and 
Encephalitic). 

Inflammation at birth, 109; 
after birth, 170. 

Influenza, 158. 

Ingenuity in games, 232. 

Inheritance, ancestral, 166 ; 
neuropathic, 12; of mental 
instability, 182; by trans- 
mission, 13. 

Inherited nature of mental de- 
fect, 57; factors, 178-188; 
table of, 179; power of de- 
velopment, 65; power of 
growth, 65. 

Injury, 109 ; to foetus, 179, 189, 
192, 194; to brain, 170; to 
child at birth, 120. 

Innate, influences, 167 ; power in 
nerve cells, 191, 175. 

Insanity, 119, 179, 180; family 
history of, 119, 180. (See 
Lunacy). 



INDEX 



299 



Inspection of school children, 
29. 

Institutions, list of, in England 
and Wales, 259-264; in 
Scotland, 264; in Ireland, 
264; in America, 265-268; 
and care, 19; a necessity, 
14; Royal Albert, 47; resi- 
dential, 35. 

Intelligent backward children, 
114. 

International Congress of Hy- 
giene and Demography, 5. 

Interpretation deficient, of sen- 
sations, 93. 

Intra-uterine life, 109. 

Iowa, 177. 

Ireland, 20. (See Howe, 264). 

Ireland, Dr., 55. (See Gene- 
tous). Also, 97, 134, 186. 

Iron, 160. 

Irregularity, of development, 
242 ; of nerve cells in men- 
tal defect, 171; of mental 
powers, 172; of skull, 59. 

Isolation, for swearing, 210; for 
nervousness and temper, 
240; rooms, 240. 

Itard, 1. 20. 



Jackets, 216. 

Jam, 210, 211. 

Jaw, deformities, 63, 103; pro- 
truding, 64, 104. 

Jerseys, 214. 

Judicial Authorities,' 40, 41, 51; 
(See Petition to), 

Juvenile General Paralysis, 114. 



K 



Kallikak family, 162, 163, 186. 
Keller, Miss Helen, 112, 194. 
Kerr, Dr., 31. 
Kidney trouble, 218. 
Kindergarten work, 229. 



Kitchens, 225. 

Kneelers, 225. 

Knives, 212. 

Knitting, 230; with twigs, 240. 

Knowle Asylum, 3. 



Labials, 94, 251; Labio-dentals, 
94. 

Labour, 189, 192. 

Lace making, 236. 

Lacing boots, 230. 

Lalling, 94, 122; conclusions as 
to, 94. 

Lancashire and Cheshire 
Society, for permanent care, 
7, 27; Asylums Board, 23. 

Lancaster, 20. 

Langdon Down, Dr., 100. 

Language, bad. (See Swearing, 
210). 

Lankester, Sir E. Ray, 13. 

Lapage, Dr., and definition of 
Feeble-mindedness, 242. 

Larynx, 89. 

Latency of taint, 203. 

Laundry work, 87. 

Lavatory, 219. 

Law relating to mentally defec- 
tive, 21; legal books, 281; 
legislation, 14. 

Legge, Mr, 16. 

Lesions, 109, 192. 

Lessons, variety in, 232. 

Levy, Mr Ben, 244. 

Lewis, David, Trustees, 244. 

Lewis, Dr. Bevan, 12. 

Lice, 158, 209, 220. 

Life, history after conception, 
167. 

Lifelong care, essential, 197; 
and parents, to ensure it, 
198; character, 11. (See 
Permanent). 

Lincoln, proportion of feeble- 
minded in, 15. 

Linguals, 94; Linguo-dentals, 
94; Linguo-palatals, 94. 



300 



INDEX 



Linking paths, 89. (See Asso- 
ciations). 
Linoleum, 217. 
Lip, movement, 92; memory of, 

90 ; reading, 129. 
List of Homes, 259 et seq. 
Liver disease in alcoholism, 183. 

(See Cirrhosis). 
Liverpool, Miss Grayson's 

Home, 7. 
Lobule, 61. 
Local, Government Board, 19, 

21 ; Education Authorities, 

21. (See Blind and Deaf). 
Loch, C. S., 9. 
Lodging-houses, 10. 
London, County Council 

Schools, 5; School Board, 

31. see also, 24. 
Lotion, antiseptic, 116. 
Lunatic, 1, 10, 14; Asylums, 40; 

definition, 1, 10. (See 

Dement). 
Lunacy Act, 1, 21; laws, 9. 

(See Insanity). 
Lunch, 211. 
Lungs, 89. 
Lysol, 156. 



M 



Mackenzie, Dr., 64. 

Macrame work, 230. 

Magdalen Hospital School, 3. 

Maintenance, 25, 51 ; at 
Colonies, 45. 

Make-believe, 240. 

Malaise, 156. 

Management of feeble-minded, 
207. (See Discipline). 

Manchester, proportion of 
feebleminded in, 14, 183; 
Children's Hospital, Pendle- 
bury, 56; family history of 
1,000 cases, 180; size of 
families, 201, 202; Special 
Schools, 56; School Board, 
8. 

Mangle and lazy worker, 236. 



Mannerisms, 123. 

Manners, 212. 

Manor House, 244. 

Manual tasks, 74; work, 86; 
skill, 119. 

Marching, 148. 

Markings on skull, 246. 

Marriage of blood relations, 201, 
205; of feebleminded, 20. 

Massage, 111. 

Masturbation, 142. 

Mats, 197; making of, 236. 

Maternal blood, 169. 

Matron, 208, 245. 

Mattresses, 217; and felt in 
place of, 217. See also, 150, 
Beds. 

Mcllraith, Dr., 65, 193, 246. 

Mean, average, 164. 

Measure, 116. 

Measles, 157; as a cause, 112; 
case caused by, 195. 

Meat food, 210. 

Medical, Officer, 25 et seq. ; and 
diet, 214; re fitness for 
schools, 29, 114; investiga- 
tors, 9; charities, 10; certi- 
ficates, 41. 

Medico-Psychological Associa- 
tion, 33. 

Melancholia, 77. 

Melland, Dr., 15. 

Memory, 71, 74, 119, 123, 126; 
storing up of movement, 90 ; 
defects of, 91 ; testing, 123 . 

Mendel, 165; Mendelism, 165; 
Ratios, 166. 

Meningitic type, 99, 112. 

Meningitis, with fits, 173; as a 
cause, 173, 176, 189, 195; 
and prognosis, 136; defini- 
tion, 172, 173. 

Mental, capacity, 78; character- 
istics, 70-88, 103; degenera- 
tion, 48; inertia, 73]^ weak- 
ness, 18. 

Mental, deficiency, 179; Act, 1, 
10, 23, 33, 53 ; (see Amentia 
and Feeblemindedness) ; 

classification, 10; defini- 



INDEX 



301 



tions, 10 and 11 ; defect, 
family history of, 119, 180; 
in early life, 127; a varia- 
tion, 174; and animals, 146; 
in animals, 176; instability, 
inherited, 182; shock as 
cause, 189, 190, 195; limita- 
tions, 136; as cause of 
neuropathic inheritance, 57; 
hygiene, 43 ; stigmata, 141 ; 
stress during pregnancy, 
119; faculties, 79. 

Mentality, 253. 

Menstruation, 67. 

Mercier, Dr., 13. 

Mercury, 165. 

Methods, 23-54; also 9, Ameri- 
can, 42. 

Metropolitan, Asylums Board, 3. 

Microcephaly, -lie, 55-57, 106, 
138, 176; (see Types); and 
garden, 78; family of, 106, 
107; prognosis in, 108; path- 
ology, 107; causation, 106; 
spasticity, 107; characteris- 
tics, 108; treatment, 108. 

Midland Counties Asylum, 3; 
Midland County Voluntary 
Association, 37. 

Miliary tuberculosis, 105. 

Milk, in diet, 211. 

Mimicry, 105. 

Minced meat, 211. 

Mind, development of, 70. 

Ministry of Health, 25. 

Mirror writing, 86. 

Miscellaneous defects, 67. 

Mitchell, Dr., 292. 

Mixture of stocks, 162. 

M'Kenna, The Right Hon. R., 
20. 

Moberly, Gen. F. J., 5. 

Models, 228; model arrange- 
ments, 28, 29. 

Modesty, 80, 142. (See De- 
cency). 

Modifications, 285. 

Mogridge, 176. 

Mongols, 55-57, 176 (see Types); 
and ear in, 62, 102; parents 



of, 101, 187; thyroid gland 
in, 103; characteristics, 101, 
103; cataract in, 104; causa- 
tion, 101 ; operations on, 
150; ages of parents, 102; 
other children in family 
containing, 101 ; and game 
with string, 75; twins, 202; 
definition, 101 ; pathology, 
102; prognosis, 105, 106, 
138. 

Moral defectives, definition, 11 ; 
imbeciles, 11, 14, 19; prog- 
nosis, 143; see also, 70, 78, 
80, 82, 114. (See Natural 
Criminals). (See Plate IX). 

Morally incapable, 17. 

Moron, 87. 

Morphological, 285. 

Mortality, 15, 13, 134. 

Mott, Dr., 16, 18, 183. 

Mouth, 88. (See Oral). 

Movements, aimless, 128. 

Mumps, 157. (See Parotid). 

Murdoch, Dr., 106. 

Muscles, control over, 68, 138; 
sensations of, 89. See also 
92. Hypotonia of, 102. 

Muscular sensations, 71, 91. 

Music, 105, 148. 

Mutation, 164, 165 ; and environ- 
ment, 165; and natural 
selection, 165 ; and Mongol- 
ism, 176; and Microcepha- 
lics, 176. 

Myxoedema, 99; congenital. 
(See Cretinism). 



N 



Napkins at table, 213. 

Nasion, 61. 

Natal, 189, 285; period, 189; 

causes, 192; injuries, 192. 

(See Birth). 
Natality of mentally defective, 

15. 
National Association for Care of 



802 



INDEX 



Native race, 176. 

Natural criminals, 82. (See 
Moral Defectives). 

Natural selection, 164, 165, 176, 
285. 

Nature and Nurture, 164. 

Neatness, 84. 

Needham, Dr. F., M.D., 9. 

Neglect and results, 132. 

Nerve, cells of brain, 78, 170; 
paths, 111 ; centres, 111 ; in 
mental defect, 170; number 
determined early, 175; con- 
trol over, 68; influences, 68. 

Nervousness, 120, 241. 

Nervous system, 179, 136. 

Neuroglia, 170. 

Neuron, 108, 109, 286. 

Neuropathic, inheritance, 57, 
179; diathesis, 121; taints, 
102; persons and alcohol, 
182, 183. 

Neurosis, 179 ; family history of, 
180. 

Newark State Custodial Home, 
44. 

Newman, Sir George, 28, 37. 

Newton, Mr, 6. 

Norbury Farm, 244. 

Norsworthy, 78. 

Norway, 177. 

Nose, in Mongols, 103; care of, 
149. 

Nucleus, 286. 

Numerals, 251. 

Nurture, 164, 286. 

Nurse, 208, 241. 

Nystagmus, 63, 104. 



Obesity, 65. 

Observation, Homes, 34; tests, 
132. 

Obstinacy, 75. 

Occipital, 58 ; defects, 58 ; exter- 
nal protuberance of, 247. 

Occupation, need for and makes 
happier, 195, 198; useful, 



230; key-note of success., 
207. 

Odour, 68. 

Offices, situation of, 222 ; in hos- 
pital, 222; use of, 222, 
cleanliness in, 222; paper 
for 222. 

Oil, Cod Liver, 214. 

Operations, 108, 150. 

Opportunities for mental devel- 
opment, 120, 126. 

Oral, 88. (See Mouth). 

Orange, H. W., 6. 

Order of birth of parents, 181. 

Organic heart disease, 65. 

Origin, 14; developmental, 57; 
congenital, 64. 

Ormond, Dr., 104. 

Outdoor relief, 10. 

Outside world, avoidance of, 
241. 

Overcoats, 214. 

Overeating, 211. 

Overwork, 232. 

Ovum, 161. 

Oxycephaly, 114. 



Palate, defects of, 63, 104, 
121 ; cleft, 64 ; imperfect de- 
velopment of, 121 ; muscles 
of, 92 ; see also 89. 

Palpebral, 104. 

Pain, insensitiveness to, 67; sen- 
sitiveness to, 76, 209; (see 
Senses). 

Paralysis, of arm improved by 
exercise, 139, 226; pseudo- 
hypertrophic, 68 ; juvenile 
general, 114. 

Paralytic types, 55-57, 99, 109; 
causation, 110; skull defor- 
mities in, 110; illustrative 
cases, 111. 

Parents, child of two feeble- 
minded, 161, 175; reports, 
119, 125; control, 39; age 
of, 187; marriage of, 179; 



INDEX 



303 



relationship of, 119, 179; re- 
sponsibility for education of 
children, 198; courses open 
to, 199. 

Parietal, 247, 286. 

Parke's Museum, 5. 

Parotid. (See Mumps). 

Parrot speech, 123. 

Parry, Alderman, 46. 

Passions, 233. 

Paths of the brain, 70, 71. 

Pathology, and heredity, 174; 
of mental defect, 170; of 
Mongolism, 102; of micro- 
cephaly, 107; definition, 
286; and evidence, 174. 

Patterns, 230. 

Peas, dwarf, and tall, 166. 

Pearce, Dr., 65, 105. 

Pearson, Professor Karl, 166, 
183. 

Peculiarities, mental, 70. 

Pediculosis, 159. (See Vermin 
on Head). 

Pedigrees, 181. 

Periodicals, 282. 

Permanent Care, results of, 27; 
legality of, 28; essential, 
197, 205; in America, 42; 
how to obtain, 199; sugges- 
tions for, 203, 205, 243. 
(See Lifelong Care). 

Perverts, 203. 

Peterson, Dr., 58, 63, 190. 

Petitions to Judicial Authori- 
ties, 40. 

Petticoats, 216. 

Phillips, Mr H., 244. 

Phlegmatic temperament, 76. 

Phrases of speech, 251. 

Phthisis, 136. (See Tubercu- 
losis). 

Physical, defects, 57; stigmata, 
118, 140; deformity, 192; 
characteristics, 64, 103, 121 ; 
injury during pregnancy, 
189, 190; drill, 111, 148; 
exercise, 65. 

Physically defective, schools for 
the, 5. 



Physique, 65. 

Pica, 141. 

Pictures in rooms, 217. 

Pigs, 245. 

Pinafores, 216. 

Pinna, 61, 286. 

Pinsent, Mrs Hume, 9, 37. 

Pituitary body in Mongols, 103, 
286. 

Plaiting cloths, 230. 

Plans of Wyatt House, 270, 271. 

Plasm, germ-, 161, 162, 174. 
(See Somatic and Proto- 
plasm). 

Plates, 226. 

Playgrounds in Special Schools, 
148. 

Plica semilunaris, 63. 

Ploughing, 76. 

Pneumococcal meningitis, 112. 

Pneumonia, 105, 136. 

Pockets in clothes, 215. 

Poisons, 181. 

Police, 10. 

Pooley, Mr, 6. 

Poor Law, relief and mental de- 
fect, 40; Guardians, 3, 23, 
24; Authorities, 3, 23, 25, 
27, 200; Institutions, 10; 
Board of, 26. 

Porencephaly, 173. 

Post-natal, period, 189, 193; in- 
flammation, 170; causes, 
189, 193. 

Postbasic meningitis, 112. 

Potassium iodide, 111. 

Potatoes, 211 ; peeling as an 
occupation, 226, 237; and 
work for hemiplegic case 
(potato peeler), 226. 

Potts, Dr., 5, 191. (See 
Shuttleworth). 

Poultry, 245. 

Powers of the brain, 70. 

Prayers, 232. 

Pregnancy, alcoholism during, 
184; health during, 118, 
119; and syphilis, 185. 

Prematurity as cause, 193. 

Present methods of dealing with 



304 



INDEX 



mental defect, 23-54; condi- 
tions, care under, 199; 
methods of relief, 38. 

Pressure, 192. 

Preventative measures, 197-205; 
asexualization as a, 203; 
summary as to, 205. 

Primary cases, 12, 55, 179; 
cause of, 179. 

Principles, of treatment, 197- 
205 ; of Royal Commission's 
recommendations, 199. 

Prisons, 10; prisoners, 17. 

Private individuals and guar- 
dians, 38. 

Probability of improvement, 
137. 

Progeria, 114. 

Prognathism, 64, 141. 

Prognosis, 134-144; in moral 
defectives, 143; in cretin- 
ism, 100; in Mongolism, 
134; in microcephaly, 108. 

Progress at school, 127. 

Progressive variations, 163 ; 
mutations, 165. 

Prolonged labour as a cause, 
188, 192. 

Proportion of feebleminded to 
general population, 14. 

Prostitute, 197. 

Protection, of unfit, 52. (See 
Board of Control, 23). 

Protoplasm, 286. 

Pseudo-hypertrophic paralysis, 
68. 

Psychological Laboratory, 117. 

Puberty, fits at, 68. 

Public Authorities, 34; Elemen- 
tary Schools, 10. 

Publications, Acts, etc., 281, 
282. 

Pudding, 213. 

Pulmonary, 105. 

Punishment, 81. 

Puzzles, 231. 



Q 



Quilt, 217. 



R 



Quarantine, 156. 



Race, native, 176. 

Radius of skull, 247. 

Radnor, Earl of, 8. 

Rankine, Dr., 105. 

Reading, 231 ; power of, 119, 
127; area in brain, 72. (See 
Diagram VI). Inability to, 
85. 

Reasoning, powers, 124; teach- 
ing of, 230. 

Rebuke, 77. 

Reception paths, 70, 88; and 
speech, 91. 

Receptive power of brain, 70. 

Records, the taking of, 116; 
points to be noted, 118. 

Reformatory, 10, 17. 

Registrar-General on size of 
families, 201. 

Registration of mental defect, 
need of system, 186. 

Regressive variation, 287. 

Regularity of meals, 212. 

Regulations and rules, 21. 

Regulation, of mental defect, 
book on, 149; of Special 
Schools, 149; of Board of 
Education, 227. 

Reid, Dr. Archdall, 13. 

Reports, and Acts, 268, 287; on 
mental and physical condi- 
tion of childhood, 6. 

Reproduction, 161, 166, 174; 
bi-parental, 161. 

Rescue Homes. (See York). 

Reserve, 79. 

Resistance to disease, 134. 

Responsibility, 242 ; as an aid to 
treatment, 144. 

Retrogressive variation, 163 ; 
mutation, 165. 

Reversion, 164; variations, 164. 

Rheumatism, 158. 

Richards, Mr, 246. 

Richardson, Dr., 175. 






INDEX 



305 



Rickets, 83, 113; head, 59; as 
a cause, 195. 

Ringworm, 158. 

Rivalry, 232. 

Rocking-horse, 223. 

Ronuk, 216. 

Rooms, dining and day, 223, 
224; school, 227; manual, 
228. 

Routine of day, 272. 

Royal, Albert Asylum, 3, 47, 
147, 181; Schools for the 
Deaf, 129; Edinburgh Asy 
lum, 19; Royal Commis 
sion, on the inherited nature 
of feeblemindedness, 180 ; 
on care and control of the 
feebleminded, 8; on alcohol 
as a cause, 180; on Blind, 
Deaf, and Dumb, 4. 

Rug making, 230. 

Rules. (See Regulations). 

Ruspini, Mrs, 19. 



Salvation Army, 33. 

Sandlebridge, 8, 27, 35, 51, 
65, 68, 82, 135, 154; ac- 
count of, 243 ; small amount 
of tuberculosis at, 184; 
feeding at, 213; tooth 
brushes at, 220. 

Sanem (consanguinite), 187. 

Sanguine temperament, 76, 

Sanitary Authorities, 10. 

Sassafras, Oil of, 160. 

Savage, Dr., 16. 

Scabies, 159. 

Scalding, 209. 

Scarlet fever, as a cause, 112; 
description, 195. 

School, rooms, 227; standards 
at, 119, 125; decorations in, 
227; residential, 26; pro- 
gress at, and prognosis, 
143; special, 31, 114, 129; 
training, 51 ; book of regu- 
lations of, 149; leaving, 
235; residential and value 
U 



of, 234; list of certified, 41 
and 42. (See Special 
Schools). (See Industrial 
School System). 

Sclerosis of brain, 112, 171, 287. 

Scotland, alcohol at periods in, 
186. 

Scott, Dr., 16. 

Scott, Miss, 7. 

Scott, Mr Leslie, 47, 49. 

Secondary, causes of feeble- 
mindedness, 55, 179; caused 
by, 179 ; mental defect, 173, 
177, 179; case of, 55. 

Segregation, 287. 

Selective action of toxin, 164, 
190. 

Self consciousness, 67. 

Sensation, defective, 91 ; of 
speech, 93, 122. 

Sense, deprivation, 112, 189, 
194; development of, 236; 
-room, 228. (See Pain). 

Sensitiveness, 76. 

Sequin, 1. 

Serving of meals, 212, 213. 

Sewing, 230. 

Sexes, division of, 243. 

Sexual perverts, 203. 

Shadwell, Mr, 17. 

Shame, 79. 

Shann, Sir T. T., 246. 

Sharpe, Rev. F. W., 6. 

Shaw, Dr., 109. 

Sherlock, 86, 172. 

Shirts, 214. 

Shock, mental, 195; as a cause, 
189, 190, 195. 

Shoes, 215. 

Shortcomings, aware of, 124. 

Shuttleworth, Dr., 4, 5, 6, 58, 
102, 134, 183, 202. 

Shyness, 79, 120. 

Sick-room, 240. 

Sight, 70, 119, 228; tested, 122. 
(See Visual). 

Simon, 124, 130, 283, 253. 

Simpleness of feebleminded chil- 
dren, 197. 

Sit up, age at which, 127. 



INDEX 



Size of families containing 
feebleminded children, 201. 

Skin, 121 ; disease, 68. 

Skinner, Miss, 19. 

Skipping, 148. 

Skull, 58; bones of, 247; (see 
Cranial); defects, 58, 103, 
114; arc of, 247. 

Slavering, 69, 111; in paraly- 
tics, 111. 

Slippers, making for Matron, 
239. 

Smallness of skull, 58, 102. 

Smell, 228, 229; and substances 
for testing, 229. 

Smith, Professor W., 6. 

Socially dangerous, 17. 

Societies for feebleminded, 
addresses of, 268. 

Sociological factors, 179, 187. 

Socks, 215. 

Solitary life bad, 201. 

Sore throat, 158. 

Somatic plasm, 161. 

Sorting classes, 127. 

Spade, 235. 

Spasticity, 107. 

Special, Committees, 5; schools, 
4, 5, 7, 31, 143, 147; and 
control at leaving, 198; 
types, 99-114. 

Speech, palate and effect on, 
64; mechanism, 89; develop- 
ment of power of, 83; area 
in brain, 72; (see Diagram 
VI.); defects of, 83, 89-98, 
122, 231 ; conclusions as to 
nature of defects, 88 ; causa- 
tion of defects, 83, 90, 93; 
testing of, 93, 126, 250; 
teaching of, 90; cases illus- 
trating, 253; detailed exam- 
ination, 250 and 251 ; 
methods of, 250; effect on 
diagnosis, 119; effect on 
prognosis, 119. 

Spina Bifida, 113. 

Spontaneous feeblemindedness, 
181. 

Sports, 164. 



Squint, 63, 104. 

Stacey, Miss, 7. 

Stammering, 120 and 97. 

Standard at school for normal 
child, 125. 

Starcross Western Counties 
Asylum, 3. 

State Institutions, 41. 

Stationery Office, 149. 

Statistics, 1-22, 55, 192 and 193 ; 
re Mongols, 102 ; of alcohol- 
ism, 183. 

Stays, 216. 

Steeple skull, 114. 

Sterilization, surgical, 203. (See 
Asexualisation). 

Stewart, G., M.P., 20. 

Stigmata of degeneration, 57, 
100, 121, 175. 

Still, Dr., 56, 104, 134. 

Store-rooms, 225. 

Stowell, Dr., 135, 136. 

Strabismus, 63. 

Stress, mental, 190. 

Stuttering, 97. 

Substances, 229. 

Suet, 211. 

Suggestions for permanent care, 
199. 

Suicide, 77, 188. 

Sulphur candle, 156. 

Summary as to preventative and 
social measures, 205. 

Sunday suits, 215. 

Sunlight, 155. 

Sunstroke, 189, 195. 

Supernumerary auricles, 65. 

Supervision, of mental defec- 
tives, 34; need for, 198. 

Surgical, measures, 14; steriliza- 
tion, 203. 

Survival of mental defectives, 
201. 

Sutures, 106. 

Swearing, 210. 

Sv.eets, 212. 

Synostosis, 287. 

Syphilis, 119, 184, 189; Wasser- 
mann's reaction in, 185; 
congenital, as a cause, 195. 






INDEX 



307 



Tablecloths, 213; waiting at, 
213; manners, 212. 

Tactile, 91. (See Touch). 

Taint, in stocks, 180, 181; 
transmitted, 179, 181; un- 
balanced, 164; neuro- 
pathic, 102 ; alcoholism, 
18, 183. 

Talking at meals, 212; ab- 
sence of, 232; develop-* 
ment of power of, 82, 108, 
127; delayed, 68, 82, 127; 
average ages of, 83, 138. 

Taps, kind of, 221. 

Taste, 228. 

Taylor, Dr, 65. 

Tea, 211; as beverage, 210. 

Teachers, 31, 34, 80, 125, 198; 
report, 119. 

Teaching, 5, 26 et seq. 

Teeth, 89; care of, 149; 
cleaning of, 220. 

Temperament, 76, 119, 142. 

Temperature, 236. 

Tempers, control of, 233; hys- 
terical, 236; rest cure for, 
241. 

Temporary mental affections, 
11; insanity, 12. 

Temptations, 198. 

Tests, of hearing, 122; by ob- 
servation, 132. 

Text-books, list of, 275-288. 

Thomas, Dr, 90. 

Throat, care of, 149; muscles 
of, 92. 

Thumb, Tom, 114. 

Thyroid gland, 99, 139, 189; 
extract, 65, 153; in Mon- 
gols, 103; in Cretins, 99. 

Ties, 215. 

Tissues, 68. 

Toffee, 212. 

Tom Thumb. (See Ateleiosis). 

Tongue, 64, 89, 92, 103; clum- 
siness and deficient sensa- 
tion of, 91; depressor, 116; 
-tie, 92. 



Tonsils, 150; Tonsilitis, 158. 

Tooth-brushes, care of, 220. 

Touch, testing cupboard, 228, 
229; bag, 229; see also 
71. (See Tactile). 

Towels, care of, 221. 

Townsend, Miss, 6. 

Toxic influences of germ-plasm, 
164, 190. 

Toys, 217, 240, 209, 224. 

Tracings, of heads, 59, 61; 
Plate III., 60. 

Tragus, 61, 247. 

Training, of feebleminded, 3, 
207; Homes, 10. 

Transmission, 13, 179. 

Treatment, and care, 144-160; 
at home, 146; of feeble- 
minded children, 116, 145- 
160; of Mental Defectives, 
34, 116; of Cretinism, 100; 
of Mongols, 106; of Micro- 
cephaly, 108; of Paraly- 
tics, 111 ; of Hydrocephaly, 
118; principles of, 198; 
grounds for, 17. (See also 
Appendix I.). 

Tredgold, Dr A. F., 12, 15, 16, 
47, 134, 169, 172, 180, 183, 
184, 202. 

Troup, Mr., 17. 

Trouser-linings, 215. 

Tubercles of ear, 61. (See 
Darwin). 

Tuberculosis, 184; statistics of 
family history, 119, 183; 
during pregnancy, 179, 189, 
192; at institutions, 154; 
in Mongols, 195. (See 
Consumption). (See Phthi- 
sis). 

Tuberculous disease, 83, 136. 

Tumour, 189. 

Types, 99-115; 55, 138; moral 
defective, 70; melancholic, 
77. 

U 

Unevenness of mental develop- 
ment, 145, 172. 



308 



INDEX 



Unselfishness, 79. 

Unsocial disposition, 240. 

Unsound mind, definition, 10. 

Unit characters, 165. (See 
Mendel). 

United States of America, pro- 
vision in, 44. 

Utensils, 226; in hospital, 241. 



Vacancy, mental, 147. 

Vanity, 80. 

Variations, 163; inborn, 163; 
progressive, 163, 174; re- 
trogressive, 163, 174; ac- 
quired, 163 (modifications); 
germinal, 12 ; reversive, 
164, 174; feeblemindedness 
a, 175; and mutation „ 174; 
ratio of, 12. 

Vegetables, 211. 

Ventilation, 155, 217. 

Ventricles of brain, 113. 

Vermin in head, 159, 209. (See 
' Pediculosis). 

Vests, 215, 216. 

Vice, 204. (See degradation). 

Visitors, 34, 50; and pediculi, 
220. 

Visual sensations, 77; area, 90. 
(See Sight); image, 77. 

Vitiating habits or disease, 179, 
182; conclusions as to, 184. 

Vocal cords, 89. 

Voluntary, Agencies, 7; Socie- 
ties, 22, 23, 34; Associa- 
tions, 33. 

W 

Wage-earning, 20; power, 199. 
Waistcoats, 215. 
Walker, Mr James, 246. 
Walking, development of, 68, 

82, 108, 127; average ages, 

83, 138. 

Want of control, 68. 
Wardrobe, 224. 



Wardship, 200. 

Warford, Great, 244; Hall, 
244. 

Warner, Dr. F., 4, 5, 63. 

Wassermann Reaction, 185. 

Waste of food, 213, 225. 

Wasting disease, 83. 

Water, supply of, 221 ; closets. 
(See Offices). 

Watering plants in rain, 78. 

Waugh, Mr., 47. 

Waverley, Institution, 43, 135, 
154, 213; bathrooms and 
lavatories, 219; sense-room, 
228. 

Ways, into brain, 90; out of 
brain, 91. 

Weakminded, 17 ; weakness 
(mental), 18. 

Weaving, 236. 

Wegener, 86. 

Weights and heights, 64, 105, 
118, 121. 

Weismann's doctrine, 161. 

Whistle, 74. 

Wilhete, Dr., 173. 

Wilkinson, Mr. Frederick, 12. 

Will, power, 74, 91, 97; de- 
fects of, 91 ; case illustra- 
ting defectives 75; record 
of, 119; in paralytics, 111. 

Wilmarth, Dr., 173. 

Windows, 217. 

Winter shirts, 214. 

Women, feebleminded, means 
of helping, 7. 

Word, blindness and deafness, 
90; storing up of, 89; for 
testing speech, 251. 

Work, 234; suitable for feeble- 
minded, 234, 238; for low- 
grade cases, 43; at potato 
machine, 236; change to, 
from school, 235; varia- 
tions in, 238; importance 
of, 49; value of, 233; 
choice of, 235, 238; and 
money result of, 238; men 
and girls at, 238 ; at Sandle- 
bridge, 245. 



INDEX 



309 



" Workers and wastrels," 43. 

Workshop, 197. 

Writing, 231 ; power of, 119, 
127; area in brain, 72 (dia- 
gram VI.); inability, 85 
(see Mirror-); and inter- 
communication by, 231. 

Wyatt, C. H., 8, 245; C. H., 
jun., 245. 

Wyatt House, plans of, 270, 
271. 



Wyllie, Dr., 91; Physiological 
Alphabet, 94 et seq. 



York, Rescue Homes, 19; 

Union Infirmary, 19. 
Youth, continued. (See Atel- 

eiosis). (See Tom Thumb). 



r 



Mi 



